MEDICARE: CRESTWOOD NURSING AND CONVALESCENT HOME INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	628	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205822517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTWOOD NURSING AND CONVALESCENT HOME INC

Provider Business Mailing Address
First Line	:	568 CHILD ST
Second Line	:
City	:	WARREN
State	:	RI
Zip	:	02885-1734
Country	:	US
Telephone Number	:	401-245-1574
Fax Number	:	401-247-0211

Provider Business Practice Location Address
First Line	:	568 CHILD ST
Second Line	:
City	:	WARREN
State	:	RI
Zip	:	02885-1734
Country	:	US
Telephone Number	:	401-245-1574
Fax Number	:	401-247-0211

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. GARY M MINASSIAN
Credential	:
Telephone Number	:	401-245-1574

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	10/19/2015

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