Provider Demographics
NPI:1700128428
Name:CRYSTAL MEADOWS ESTATES, LLC
Entity type:Organization
Organization Name:CRYSTAL MEADOWS ESTATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-479-9856
Mailing Address - Street 1:4173 HEARTHSIDE DRIVE
Mailing Address - Street 2:104
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-8335
Mailing Address - Country:US
Mailing Address - Phone:954-479-9856
Mailing Address - Fax:
Practice Address - Street 1:4173 HEARTHSIDE DRIVE
Practice Address - Street 2:104
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-8335
Practice Address - Country:US
Practice Address - Phone:954-479-9856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness