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General NPI Number Information
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NPI Number | 1144689852
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Entity Type | Organization
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Legal Business Name | CRESTWOOD HOUSE LLC
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Dates
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Enumeration Date | 02/23/2016
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Last Update Date | 02/23/2016
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Provider Practice Location Address
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Address Line | 848 CRESTWOOD AVE
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City | TITUSVILLE
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State | FL
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Zip | 32796-2264
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Country | US
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Telephone | 321-501-3280
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Fax |
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Provider Business Mailing Address
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Address Line | 848 CRESTWOOD AVE
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City | TITUSVILLE
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State | FL
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Zip | 32796-2264
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Country | US
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Telephone | 321-501-3280
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Fax |
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Authorized Official
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Title or Position | MGMR
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Name | DAVID ALAN MCKNIGHT
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Credential |
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Telephone | 321-501-3280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL12735
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License Number State | FL
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