Basic Information
| Provider Information | |||||||||
| NPI: | 1437130747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLO-GP LEASING CO., LLC | ||||||||
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| OtherOrganizationName: | CRYSTAL CREEK HEALTH AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 ASHWOOD DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452412465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134897100 | ||||||||
| FaxNumber: | 5135301359 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 S NEW FLORISSANT RD | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630316716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148382211 | ||||||||
| FaxNumber: | 3148385981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | STOLTZ | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5134897100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320700000X | N | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities | 314000000X | 030945 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 107807703 | 05 | MO | MEDICAID |