Provider Demographics
NPI:1952301822
Name:CRYSTAL PINES REHABILITATION AND HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:CRYSTAL PINES REHABILITATION AND HEALTH CARE CENTER, LLC
Other - Org Name:CRYSTAL PINES REHABILITATION & HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:TUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-444-0900
Mailing Address - Street 1:335 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3618
Mailing Address - Country:US
Mailing Address - Phone:815-459-7791
Mailing Address - Fax:815-459-7680
Practice Address - Street 1:335 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3618
Practice Address - Country:US
Practice Address - Phone:815-459-7791
Practice Address - Fax:815-459-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0045062314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL431821821001Medicaid
IL145257Medicare Oscar/Certification