Provider Demographics
NPI:1578563342
Name:MRC CRESTVIEW
Entity Type:Organization
Organization Name:MRC CRESTVIEW
Other - Org Name:CRESTVIEW RETIREMENT COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-210-0138
Mailing Address - Street 1:2505 E. VILLA MARIA ROAD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2038
Mailing Address - Country:US
Mailing Address - Phone:979-776-4778
Mailing Address - Fax:979-774-7579
Practice Address - Street 1:2505 E. VILLA MARIA ROAD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2038
Practice Address - Country:US
Practice Address - Phone:979-776-4778
Practice Address - Fax:979-774-7579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114290314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0010033963Medicaid
TX004350Medicaid
TX001003963Medicaid