Healthcare Provider Details

I. General information

NPI: 1679477657
Provider Name (Legal Business Name): CRESTWATER HEALTH AND REHAB CHARLOTTE HARBOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 KINGS HWY
PORT CHARLOTTE FL
33980-8718
US

IV. Provider business mailing address

4000 KINGS HWY
PORT CHARLOTTE FL
33980-8718
US

V. Phone/Fax

Practice location:
  • Phone: 941-255-5855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: BONNIE OREILLY
Title or Position: ADMINISTRATOR
Credential:
Phone: 941-255-5855