Healthcare Provider Details

I. General information

NPI: 1528213642
Provider Name (Legal Business Name): CRESTPARK DEWITT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 LIBERTY DR
DE WITT AR
72042-3430
US

IV. Provider business mailing address

PO BOX 589
DE WITT AR
72042-0589
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-3569
  • Fax: 870-946-0699
Mailing address:
  • Phone: 870-946-3569
  • Fax: 870-946-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number637
License Number StateAR

VIII. Authorized Official

Name: MRS. MELISHA DILKS
Title or Position: MANAGER
Credential:
Phone: 870-821-0144