Provider Demographics
NPI:1619149077
Name:CRYSTAL RUN VILLAGE INC
Entity Type:Organization
Organization Name:CRYSTAL RUN VILLAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR OF ADMIN SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMMIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-695-2559
Mailing Address - Street 1:601 STONY FORD RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-3951
Mailing Address - Country:US
Mailing Address - Phone:845-692-4444
Mailing Address - Fax:845-695-1101
Practice Address - Street 1:601 STONY FORD RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-3951
Practice Address - Country:US
Practice Address - Phone:845-692-4444
Practice Address - Fax:845-695-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities