Basic Information
| Provider Information | |||||||||
| NPI: | 1346596871 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMBASSY CRYSTAL CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24579 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441466338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404397976 | ||||||||
| FaxNumber: | 4402327113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448052810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192819595 | ||||||||
| FaxNumber: | 4192829609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2012 | ||||||||
| LastUpdateDate: | 08/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | HANDLER | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGAING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4404397976 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1268 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.