Provider Demographics
NPI:1801889985
Name:CREST HALL CORP.
Entity type:Organization
Organization Name:CREST HALL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-924-8830
Mailing Address - Street 1:63 OAKCREST AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1415
Mailing Address - Country:US
Mailing Address - Phone:631-924-8830
Mailing Address - Fax:
Practice Address - Street 1:63 OAKCREST AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1415
Practice Address - Country:US
Practice Address - Phone:631-924-8830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5151314N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995922Medicaid
NY01995922Medicaid