Provider Demographics
NPI:1639262702
Name:CRESTRIDGE LLC
Entity Type:Organization
Organization Name:CRESTRIDGE LLC
Other - Org Name:CRESTRIDGE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-822-4441
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:OKEENE
Mailing Address - State:OK
Mailing Address - Zip Code:73763-0727
Mailing Address - Country:US
Mailing Address - Phone:580-822-4441
Mailing Address - Fax:580-822-4431
Practice Address - Street 1:816 N CLARENCE NASH BLVD
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-2024
Practice Address - Country:US
Practice Address - Phone:580-623-7249
Practice Address - Fax:580-623-7245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH0603-0603313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility