Healthcare Provider Details

I. General information

NPI: 1083882682
Provider Name (Legal Business Name): CRESTWOOD HEALTH CARE CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 MEHL AVENUE
FLORISSANT MO
63033-7204
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 314-741-3525
  • Fax: 314-741-3721
Mailing address:
  • Phone: 314-543-3800
  • Fax: 314-543-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number038173
License Number StateMO

VIII. Authorized Official

Name: MR. ASHWIN DUNDOO
Title or Position: FINANCE
Credential:
Phone: 314-543-3800