Healthcare Provider Details

I. General information

NPI: 1467592618
Provider Name (Legal Business Name): CRYSTAL OAKS LONG TERM CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 CALVARY CHURCH RD
FESTUS MO
63028-4125
US

IV. Provider business mailing address

PO BOX 680
CRYSTAL CITY MO
63019-0680
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-1818
  • Fax: 636-933-1894
Mailing address:
  • Phone: 636-933-1818
  • Fax: 636-933-1894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number040114
License Number StateMO

VIII. Authorized Official

Name: JAMES V ARNOLD JR.
Title or Position: PRESIDENT & CEO
Credential:
Phone: 636-933-1897