MEDICARE: CRESTHAVEN MEDICAL SUPPLY LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1336772003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTHAVEN MEDICAL SUPPLY LLC

Provider Business Mailing Address
First Line	:	7735 HAVENS CT W
Second Line	:
City	:	BLACKLICK
State	:	OH
Zip	:	43004-9555
Country	:	US
Telephone Number	:	614-600-1544
Fax Number	:

Provider Business Practice Location Address
First Line	:	2577 S HAMILTON RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4964
Country	:	US
Telephone Number	:	614-600-1544
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. ERIC OBENG
Credential	:	B(PHARM)
Telephone Number	:	614-600-1544

Provider Enumeration Date	:	02/20/2020
Last Update Date	:	02/20/2020

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