Healthcare Provider Details

I. General information

NPI: 1013993237
Provider Name (Legal Business Name): CRESTWOOD CARE CENTRE LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14255 CICERO AVE
CRESTWOOD IL
60445-2154
US

IV. Provider business mailing address

14255 CICERO AVE
CRESTWOOD IL
60445-2154
US

V. Phone/Fax

Practice location:
  • Phone: 708-371-0400
  • Fax: 708-371-5871
Mailing address:
  • Phone: 708-371-0400
  • Fax: 708-371-5871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number44164
License Number StateIL

VIII. Authorized Official

Name: MR. MICHAEL CHARLES BRAUN
Title or Position: CONTROLLER
Credential:
Phone: 847-583-0100