Healthcare Provider Details

I. General information

NPI: 1245516194
Provider Name (Legal Business Name): CRESTVIEW-THS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 COURT ST
JANE LEW WV
26378-8548
US

IV. Provider business mailing address

838 CARTHAGE HWY
LEBANON TN
37087-4611
US

V. Phone/Fax

Practice location:
  • Phone: 304-884-7811
  • Fax: 304-884-7057
Mailing address:
  • Phone: 615-417-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number84
License Number StateWV

VIII. Authorized Official

Name: MR. GORDON BONE
Title or Position: VICE-PRESIDENT
Credential:
Phone: 615-417-8131