Healthcare Provider Details

I. General information

NPI: 1548975188
Provider Name (Legal Business Name): KREWS SUPPORTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3248 SOUTH AVE
TOLEDO OH
43609-1104
US

IV. Provider business mailing address

3248 SOUTH AVE
TOLEDO OH
43609-1104
US

V. Phone/Fax

Practice location:
  • Phone: 419-901-4789
  • Fax:
Mailing address:
  • Phone: 419-901-4789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY WHITE
Title or Position: OWNER
Credential:
Phone: 419-901-4789