MEDICARE: KREWS SUPPORTED LIVING LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	253Z00000X	In Home Supportive Care Agency
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
3	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
4	385HR2065X	Child Physical Disabilities Respite Care
5	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1548975188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KREWS SUPPORTED LIVING LLC

Provider Business Mailing Address
First Line	:	3248 SOUTH AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43609-1104
Country	:	US
Telephone Number	:	419-901-4789
Fax Number	:

Provider Business Practice Location Address
First Line	:	3248 SOUTH AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43609-1104
Country	:	US
Telephone Number	:	419-901-4789
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRITTANY WHITE
Credential	:
Telephone Number	:	419-901-4789

Provider Enumeration Date	:	01/18/2023
Last Update Date	:	01/18/2023

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