Provider Demographics
NPI:1659757110
Name:CRESTBROOK REHABILITATION
Entity Type:Organization
Organization Name:CRESTBROOK REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LAMONT
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-587-1424
Mailing Address - Street 1:2814 LIBERTY OAKS DR APT A
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-9754
Mailing Address - Country:US
Mailing Address - Phone:336-587-1424
Mailing Address - Fax:
Practice Address - Street 1:2814 LIBERTY OAKS DR APT A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-9754
Practice Address - Country:US
Practice Address - Phone:336-587-1424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness