Healthcare Provider Details

I. General information

NPI: 1659757110
Provider Name (Legal Business Name): CRESTBROOK REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 LIBERTY OAKS DR APT A
GREENSBORO NC
27406-9754
US

IV. Provider business mailing address

2814 LIBERTY OAKS DR APT A
GREENSBORO NC
27406-9754
US

V. Phone/Fax

Practice location:
  • Phone: 336-587-1424
  • Fax:
Mailing address:
  • Phone: 336-587-1424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LAMONT DEWAYNE DUNLAP
Title or Position: CEO
Credential:
Phone: 336-587-1424