Provider Demographics
NPI: | 1457608184 |
---|---|
Name: | CRESTWOOD CARE CENTER |
Entity Type: | Organization |
Organization Name: | CRESTWOOD CARE CENTER |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | SPEECH LANGUAGE PATHOLOGIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ASHLEY |
Authorized Official - Middle Name: | C |
Authorized Official - Last Name: | WESTBROOKS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MS, CCC-SLP |
Authorized Official - Phone: | 618-781-9591 |
Mailing Address - Street 1: | 11400 MEHL AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | FLORISSANT |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63034 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-741-3525 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 11400 MEHL AVE |
Practice Address - Street 2: | |
Practice Address - City: | FLORISSANT |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63034 |
Practice Address - Country: | US |
Practice Address - Phone: | 314-741-3525 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-08-13 |
Last Update Date: | 2012-11-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2012027940 | 314000000X |
IL | 242002106 | 314000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 314000000X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |