MEDICARE: CREST MANOR LIVING AND REHABILITATION CENTER INC

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	314000000X	Skilled Nursing Facility	2762301N	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CM	OTHER	NY	EXCELLUS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	P015005983	OTHER	NY	BLUE CHOICE
4	106012CI	OTHER	NY	PREF. CARE

General Provider Information

NPI Number	:	1356348874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREST MANOR LIVING AND REHABILITATION CENTER INC

Provider Business Mailing Address
First Line	:	6745 PITTSFORD PALMYRA RD
Second Line	:
City	:	FAIRPORT
State	:	NY
Zip	:	14450-3343
Country	:	US
Telephone Number	:	585-223-3633
Fax Number	:	585-425-2961

Provider Business Practice Location Address
First Line	:	6745 PITTSFORD PALMYRA RD
Second Line	:
City	:	FAIRPORT
State	:	NY
Zip	:	14450-3343
Country	:	US
Telephone Number	:	585-223-3633
Fax Number	:	585-425-2961

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. ALAN JOHN BARTHOLOMEW SR.
Credential	:	LNHA
Telephone Number	:	585-223-3633

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	01/31/2017

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