Healthcare Provider Details

I. General information

NPI: 1023068723
Provider Name (Legal Business Name): CRYSTAL REHABILITATION AND HEALTHCARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 SGT JOHN A PITTMAN DR
GREENWOOD MS
38930-7343
US

IV. Provider business mailing address

902 SGT JOHN A PITTMAN DR
GREENWOOD MS
38930-7343
US

V. Phone/Fax

Practice location:
  • Phone: 662-453-9173
  • Fax: 662-455-4933
Mailing address:
  • Phone: 662-453-9173
  • Fax: 662-455-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number501
License Number StateMS

VIII. Authorized Official

Name: MICHELLE D MEER
Title or Position: VICE PRESIDENT & SECRETARY
Credential:
Phone: 629-626-0000