MEDICARE: SUITE LIVING SENIOR CARE OF CRYSTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1639751662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUITE LIVING SENIOR CARE OF CRYSTAL

Provider Business Mailing Address
First Line	:	1824 BUERKLE RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-5245
Country	:	US
Telephone Number	:	651-770-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 DOUGLAS DR N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2480
Country	:	US
Telephone Number	:	651-770-2273
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	AUDREY MCELWAIN
Credential	:
Telephone Number	:	651-770-2273

Provider Enumeration Date	:	04/28/2021
Last Update Date	:	03/23/2023

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