Provider Demographics
NPI:1730425240
Name:CRESCO CARE LLC
Entity type:Organization
Organization Name:CRESCO CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMENCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-770-2691
Mailing Address - Street 1:PO BOX 1569
Mailing Address - Street 2:COLLEGEDALE
Mailing Address - City:COLLEGEDALE
Mailing Address - State:TN
Mailing Address - Zip Code:37315-1569
Mailing Address - Country:US
Mailing Address - Phone:646-770-2691
Mailing Address - Fax:
Practice Address - Street 1:9465 HOMEWOOD CIR
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-5105
Practice Address - Country:US
Practice Address - Phone:423-200-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health