Healthcare Provider Details

I. General information

NPI: 1639262702
Provider Name (Legal Business Name): CRESTRIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 N CLARENCE NASH BLVD
WATONGA OK
73772-2024
US

IV. Provider business mailing address

PO BOX 727
OKEENE OK
73763-0727
US

V. Phone/Fax

Practice location:
  • Phone: 580-623-7249
  • Fax: 580-623-7245
Mailing address:
  • Phone: 580-822-4441
  • Fax: 580-822-4431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH0603-0603
License Number StateOK

VIII. Authorized Official

Name: JAMES SIMS
Title or Position: OWNER
Credential:
Phone: 580-822-4441