Healthcare Provider Details

I. General information

NPI: 1215863352
Provider Name (Legal Business Name): CRESTWOOD LEGACY HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 STUDER AVE
COLUMBUS OH
43206-1637
US

IV. Provider business mailing address

942 STUDER AVE
COLUMBUS OH
43206-1637
US

V. Phone/Fax

Practice location:
  • Phone: 937-543-2738
  • Fax:
Mailing address:
  • Phone: 937-543-2738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: PAUL SIMBARASHE SHENJERE MUTISWA
Title or Position: OWNER
Credential:
Phone: 614-699-8343