MEDICARE: C.R.E. ENTERPRISE. 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	315P00000X	Intellectual Disabilities Intermediate Care Facility		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LTC61016F	OTHER	CA	PROVIDER #

General Provider Information

NPI Number	:	1891822219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C.R.E. ENTERPRISE. INC,

Provider Business Mailing Address
First Line	:	138 ROSEWOOD WAY
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-5846
Country	:	US
Telephone Number	:	650-340-0025
Fax Number	:	650-340-0414

Provider Business Practice Location Address
First Line	:	138 ROSEWOOD WAY
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-5846
Country	:	US
Telephone Number	:	650-340-0025
Fax Number	:	650-340-0414

Authorized Official
Title or Position	:	PROVIDER
Name	:	MRS. EVELYN BALATBAT RYAN
Credential	:
Telephone Number	:	650-340-0025

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	08/22/2020

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