Provider Demographics
NPI:1528295128
Name:CRYSTAL MANOR
Entity type:Organization
Organization Name:CRYSTAL MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY
Authorized Official - Prefix:MR
Authorized Official - First Name:WAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDADIN
Authorized Official - Suffix:
Authorized Official - Credentials:ADULT RESIDENTAL
Authorized Official - Phone:626-337-1424
Mailing Address - Street 1:3406 BALDWIN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4807
Mailing Address - Country:US
Mailing Address - Phone:626-337-1424
Mailing Address - Fax:
Practice Address - Street 1:3406 BALDWIN PARK BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-4807
Practice Address - Country:US
Practice Address - Phone:626-337-1424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191501799323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility