MEDICARE: AAA CRYSTAL ROSE ADULT FAMILY HOME

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	311ZA0620X	Adult Care Home Facility	603295523	WA

General Provider Information

NPI Number	:	1306277660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AAA CRYSTAL ROSE ADULT FAMILY HOME

Provider Business Mailing Address
First Line	:	PO BOX 8401
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99203-0401
Country	:	US
Telephone Number	:	509-999-7273
Fax Number	:

Provider Business Practice Location Address
First Line	:	4414 S HELENA ST
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99223-4313
Country	:	US
Telephone Number	:	509-999-7273
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. STEVEN C ANDREWS
Credential	:	R.N.
Telephone Number	:	509-999-7273

Provider Enumeration Date	:	12/11/2013
Last Update Date	:	12/11/2013

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