Basic Information
| Provider Information | |||||||||
| NPI: | 1851976658 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VANCREST OF HICKSVILLE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W MAIN ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458911761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192380715 | ||||||||
| FaxNumber: | 4192384814 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 FOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | HICKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435261337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192380715 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2021 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | HOLLIDAY | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4192380715 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.