Provider Demographics
NPI:1831350610
Name:CRESTMONT NURSING HOME NORTH CORP
Entity type:Organization
Organization Name:CRESTMONT NURSING HOME NORTH CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY / TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOX
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:440-617-2103
Mailing Address - Street 1:24340 SPERRY DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1565
Mailing Address - Country:US
Mailing Address - Phone:440-617-2103
Mailing Address - Fax:
Practice Address - Street 1:13330 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-2850
Practice Address - Country:US
Practice Address - Phone:216-228-9550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0929858291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory