Provider Demographics
NPI:1487656773
Name:CRESTMONT NURSING HOME NORTH CORP.
Entity Type:Organization
Organization Name:CRESTMONT NURSING HOME NORTH CORP.
Other - Org Name:CRESTMONT NORTH NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:COURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-539-7846
Mailing Address - Street 1:13330 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2850
Mailing Address - Country:US
Mailing Address - Phone:216-539-7846
Mailing Address - Fax:216-521-1212
Practice Address - Street 1:13330 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-2850
Practice Address - Country:US
Practice Address - Phone:216-228-9550
Practice Address - Fax:216-521-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4284313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0880793Medicaid
OH0880793Medicaid