Provider Demographics
NPI:1619967932
Name:CRESTCARE NURSING & REHABILITATION CENTER
Entity Type:Organization
Organization Name:CRESTCARE NURSING & REHABILITATION CENTER
Other - Org Name:EDEN SPECIALTY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-574-7495
Mailing Address - Street 1:1301 EDEN DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-4102
Mailing Address - Country:US
Mailing Address - Phone:903-753-7651
Mailing Address - Fax:903-758-8942
Practice Address - Street 1:1301 EDEN DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4102
Practice Address - Country:US
Practice Address - Phone:903-753-7651
Practice Address - Fax:903-758-8942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110571313M00000X, 314000000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001003848Medicaid
TX1668709-01Medicaid
TX1668709-01Medicaid
TX5028780001Medicare NSC