Basic Information
Provider Information | |||||||||
NPI: | 1043949522 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CROSSETT HEALTHCARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 150 OBERLIN AVE N STE 6 | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | NJ | ||||||||
PostalCode: | 087014535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7328006005 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1101 WATERWELL RD | ||||||||
Address2: |   | ||||||||
City: | CROSSETT | ||||||||
State: | AR | ||||||||
PostalCode: | 716354152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703645721 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2022 | ||||||||
LastUpdateDate: | 06/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | J | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CAO | ||||||||
AuthorizedOfficialTelephone: | 9174105283 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.