1891735627 NPI number — CRYSTAL CARE SUPPORT SERVICES, INC

Table of content: (NPI 1891735627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891735627 NPI number — CRYSTAL CARE SUPPORT SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CARE SUPPORT SERVICES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891735627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6461 LYNDALE AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55423-1405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-861-4272
Provider Business Mailing Address Fax Number:
612-866-2290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6461 LYNDALE AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55423-1405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-861-4272
Provider Business Practice Location Address Fax Number:
612-866-2290
Provider Enumeration Date:
06/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KNUTSON
Authorized Official First Name:
SALLY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
612-861-4272

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  21157 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21157 . This is a "CLASS A LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".