Healthcare Provider Details

I. General information

NPI: 1063165082
Provider Name (Legal Business Name): CRESTHAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 N 19TH AVE # 207-10
PHOENIX AZ
85015-3210
US

IV. Provider business mailing address

5060 N 19TH AVE # 207-10
PHOENIX AZ
85015-3210
US

V. Phone/Fax

Practice location:
  • Phone: 623-632-9009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: EMMANUEL NOUMOSSIE
Title or Position: OWNER
Credential:
Phone: 623-632-9009