Basic Information
| Provider Information | |||||||||
| NPI: | 1023535929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRYSTAL REHAB & NURSING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKSIDE REHABILITATION AND HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 PONTIAC AVE | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015701629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089433889 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11 PONTIAC AVE | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015701629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089433889 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEIBES | ||||||||
| AuthorizedOfficialFirstName: | SHIMMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMEBR | ||||||||
| AuthorizedOfficialTelephone: | 5165888811 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.