Provider Demographics
NPI:1689041865
Name:CRYSTAL FOUNTAIN HOME SERVICES LLC
Entity Type:Organization
Organization Name:CRYSTAL FOUNTAIN HOME SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-661-2724
Mailing Address - Street 1:1912 N STATE ROAD 53
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-3947
Mailing Address - Country:US
Mailing Address - Phone:850-274-3131
Mailing Address - Fax:
Practice Address - Street 1:1912 N STATE ROAD 53
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-3947
Practice Address - Country:US
Practice Address - Phone:850-274-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility