Provider Demographics
NPI:1336530278
Name:CRYSTAL COVE HOME CARE LLC
Entity type:Organization
Organization Name:CRYSTAL COVE HOME CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERLINDA
Authorized Official - Middle Name:VILLA
Authorized Official - Last Name:CANOY
Authorized Official - Suffix:
Authorized Official - Credentials:B S FINANCE
Authorized Official - Phone:480-633-7122
Mailing Address - Street 1:4492 E LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-7651
Mailing Address - Country:US
Mailing Address - Phone:480-633-7122
Mailing Address - Fax:480-248-6114
Practice Address - Street 1:4492 E LAUREL AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-7651
Practice Address - Country:US
Practice Address - Phone:480-633-7122
Practice Address - Fax:480-248-6114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL2704H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility