MEDICARE: CRESTHAVEN HEALTH CARE CENTER LTD CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
2	314000000X	Skilled Nursing Facility	114561	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164418554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTHAVEN HEALTH CARE CENTER LTD CO

Provider Business Mailing Address
First Line	:	2537 GOLDEN BEAR DR
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75006-2377
Country	:	US
Telephone Number	:	214-954-4114
Fax Number	:	214-871-3057

Provider Business Practice Location Address
First Line	:	4400 GULF AVE
Second Line	:
City	:	GROVES
State	:	TX
Zip	:	77619-3717
Country	:	US
Telephone Number	:	409-962-5785
Fax Number	:	409-962-2944

Authorized Official
Title or Position	:	CHIEF EXECUTIVE
Name	:	MRS. ROBIN UNDERHILL
Credential	:
Telephone Number	:	214-954-4114

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	09/16/2008

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Directions to “CRESTHAVEN HEALTH CARE CENTER LTD CO ” Practice Location

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