Healthcare Provider Details

I. General information

NPI: 1164590832
Provider Name (Legal Business Name): CRESTHAVEN NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 17TH AVE
SANTA CRUZ CA
95062-4122
US

IV. Provider business mailing address

740 17TH AVE
SANTA CRUZ CA
95062-4122
US

V. Phone/Fax

Practice location:
  • Phone: 831-475-3812
  • Fax:
Mailing address:
  • Phone: 831-475-3812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberZZR18059H
License Number StateCA

VIII. Authorized Official

Name: MS. MARGARET AMOS
Title or Position: ADMINISTRATOR
Credential:
Phone: 831-475-3812