Provider Demographics
NPI:1639738297
Name:CRESTWOOD BEHAVIORAL HEALTH, INC.
Entity Type:Organization
Organization Name:CRESTWOOD BEHAVIORAL HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-955-2322
Mailing Address - Street 1:7590 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-5455
Mailing Address - Country:US
Mailing Address - Phone:209-478-5291
Mailing Address - Fax:209-952-5314
Practice Address - Street 1:624 E ELDER ST
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3004
Practice Address - Country:US
Practice Address - Phone:760-451-4165
Practice Address - Fax:760-731-1377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRESTWOOD BEHAVIORAL HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness