Provider Demographics
NPI:1518733211
Name:CRYSTAL MANOR RESIDENTIAL CARE HOME, LLC
Entity Type:Organization
Organization Name:CRYSTAL MANOR RESIDENTIAL CARE HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDADIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-391-7421
Mailing Address - Street 1:3406 BALDWIN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4807
Mailing Address - Country:US
Mailing Address - Phone:626-391-7421
Mailing Address - Fax:
Practice Address - Street 1:3406 BALDWIN PARK BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-4807
Practice Address - Country:US
Practice Address - Phone:626-391-7421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness