Basic Information
| Provider Information | |||||||||
| NPI: | 1437163243 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRESTLINE FACILTY OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRESTLINE NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 CONCOURSE PKWY S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327516148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075711550 | ||||||||
| FaxNumber: | 4075711599 | ||||||||
| Practice Location | |||||||||
| Address1: | 327 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448271434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196833255 | ||||||||
| FaxNumber: | 4196834118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | CONTE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4075711550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONSULATE HEALTH CARE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2709804 | 05 | OH | MEDICAID |