Provider Demographics
NPI:1508063322
Name:CRESTWOOD BEHAVIORAL HEALTH, INC.
Entity Type:Organization
Organization Name:CRESTWOOD BEHAVIORAL HEALTH, INC.
Other - Org Name:IDYLWOOD CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-955-2322
Mailing Address - Street 1:7590 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-5455
Mailing Address - Country:US
Mailing Address - Phone:209-955-2328
Mailing Address - Fax:209-478-5385
Practice Address - Street 1:1002 W FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-3031
Practice Address - Country:US
Practice Address - Phone:408-739-2383
Practice Address - Fax:408-739-8794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05211IMedicaid
CA05-5211Medicare ID - Type UnspecifiedMEDICARE