Provider Demographics
NPI:1710940358
Name:CREST HAVEN CARE CENTER, LLC
Entity Type:Organization
Organization Name:CREST HAVEN CARE CENTER, LLC
Other - Org Name:CREST HAVEN CARE CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BENCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-758-4745
Mailing Address - Street 1:11523 PALMBRUSH TRL
Mailing Address - Street 2:SUITE 331
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-2917
Mailing Address - Country:US
Mailing Address - Phone:941-758-4745
Mailing Address - Fax:888-391-2373
Practice Address - Street 1:1000 E HOWARD ST
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-2723
Practice Address - Country:US
Practice Address - Phone:641-782-5012
Practice Address - Fax:641-782-5309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA880066314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800080Medicaid
IA0800425Medicaid
IA0236984Medicaid
IA0800080Medicaid