Healthcare Provider Details

I. General information

NPI: 1114142049
Provider Name (Legal Business Name): CRESCENT DEVELOPMENT GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 WALNUT ST
ENERGY IL
62933
US

IV. Provider business mailing address

15755 NIXON RD
NASHVILLE IL
62263-4815
US

V. Phone/Fax

Practice location:
  • Phone: 618-988-1702
  • Fax: 618-942-3345
Mailing address:
  • Phone: 618-327-9846
  • Fax: 618-327-9846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number01S002
License Number StateIL

VIII. Authorized Official

Name: MS. JANE M DODSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 618-327-9846