Provider Demographics
NPI:1528213642
Name:CRESTPARK DEWITT, LLC
Entity Type:Organization
Organization Name:CRESTPARK DEWITT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DILKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-821-0144
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-0589
Mailing Address - Country:US
Mailing Address - Phone:870-946-3569
Mailing Address - Fax:870-946-0699
Practice Address - Street 1:1325 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:AR
Practice Address - Zip Code:72042-3430
Practice Address - Country:US
Practice Address - Phone:870-946-3569
Practice Address - Fax:870-946-0699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR637314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR015177OtherBCBS PROVIDER NUMBER
ARPENDINGMedicaid
AR045177Medicare Oscar/Certification