Healthcare Provider Details

I. General information

NPI: 1871434845
Provider Name (Legal Business Name): CRYSTALHOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 DOUGLAS DR N
CRYSTAL MN
55429-3535
US

IV. Provider business mailing address

4825 DOUGLAS DR N
CRYSTAL MN
55429-3535
US

V. Phone/Fax

Practice location:
  • Phone: 651-755-5026
  • Fax:
Mailing address:
  • Phone: 651-755-5026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: OLAJUMOKE O DISU
Title or Position: OWNER
Credential:
Phone: 651-755-5026