Provider Demographics
NPI:1255340592
Name:CRESTVIEW CONVALESCENT HOSPITAL
Entity type:Organization
Organization Name:CRESTVIEW CONVALESCENT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:V
Authorized Official - Last Name:BERGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-877-1361
Mailing Address - Street 1:1471 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7703
Mailing Address - Country:US
Mailing Address - Phone:909-877-0854
Mailing Address - Fax:
Practice Address - Street 1:1471 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7703
Practice Address - Country:US
Practice Address - Phone:909-877-0854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000134314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherEIN
CA0608640001Medicare NSC
CA=========OtherEIN