Healthcare Provider Details

I. General information

NPI: 1801889985
Provider Name (Legal Business Name): CREST HALL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 OAKCREST AVE
MIDDLE ISLAND NY
11953-1415
US

IV. Provider business mailing address

63 OAKCREST AVE
MIDDLE ISLAND NY
11953-1415
US

V. Phone/Fax

Practice location:
  • Phone: 631-924-8830
  • Fax:
Mailing address:
  • Phone: 631-924-8830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5151314N
License Number StateNY

VIII. Authorized Official

Name: DR. JACOB DIMANT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 631-924-8830