Healthcare Provider Details

I. General information

NPI: 1669709176
Provider Name (Legal Business Name): CRESTWOOD CHILDREN'S CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1183 MONROE AVE
ROCHESTER NY
14620-1662
US

IV. Provider business mailing address

1183 MONROE AVE
ROCHESTER NY
14620-1662
US

V. Phone/Fax

Practice location:
  • Phone: 585-654-1418
  • Fax: 585-654-1450
Mailing address:
  • Phone: 585-654-1418
  • Fax: 585-654-1450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS GARY ANTINONE
Title or Position: ACCOUNTS RECEIVABLE
Credential:
Phone: 585-654-1418