MEDICARE: CRESTWOOD HEALTHCARE LLC

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

General Provider Information

NPI Number	:	1750915476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTWOOD HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	362 E KENNEDY BLVD
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-1434
Country	:	US
Telephone Number	:
Fax Number	:

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	:

Authorized Official
Title or Position	:	COO
Name	:	CHAIM SHAPIRO
Credential	:
Telephone Number	:	848-333-4369

Provider Enumeration Date	:	03/03/2020
Last Update Date	:	03/03/2020

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Directions to “CRESTWOOD HEALTHCARE LLC ” Practice Location

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