Provider Demographics
NPI:1790764256
Name:VANGUARD OF CRESTWOOD, LLC
Entity Type:Organization
Organization Name:VANGUARD OF CRESTWOOD, LLC
Other - Org Name:CRESTWOOD NURSING & REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:F
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-250-7100
Mailing Address - Street 1:6 CADILLAC DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5080
Mailing Address - Country:US
Mailing Address - Phone:615-250-7100
Mailing Address - Fax:615-250-7102
Practice Address - Street 1:101 WHIPPANY RD
Practice Address - Street 2:
Practice Address - City:WHIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07981-1407
Practice Address - Country:US
Practice Address - Phone:973-887-0311
Practice Address - Fax:973-887-8355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ061402314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8938407Medicaid
NJ8938407Medicaid