Basic Information
| Provider Information | |||||||||
| NPI: | 1790764256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VANGUARD OF CRESTWOOD, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRESTWOOD NURSING & REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 CADILLAC DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152507100 | ||||||||
| FaxNumber: | 6152507102 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 WHIPPANY RD | ||||||||
| Address2: | |||||||||
| City: | WHIPPANY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079811407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738870311 | ||||||||
| FaxNumber: | 9738878355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEBERT | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 6152507100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 061402 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 8938407 | 05 | NJ | MEDICAID |