Healthcare Provider Details

I. General information

NPI: 1780156208
Provider Name (Legal Business Name): CRESCENT COVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 58TH AVD N.
BROOKLYN CENTER MN
55429
US

IV. Provider business mailing address

3440 BELTLINE BLVD. STE 207
ST. LOUIS PARK MN
55416
US

V. Phone/Fax

Practice location:
  • Phone: 952-426-4711
  • Fax:
Mailing address:
  • Phone: 952-426-4711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN J. LINDENFELSER
Title or Position: EXEC. DIRECTOR
Credential: MT-BC
Phone: 952-426-4711