Healthcare Provider Details

I. General information

NPI: 1013374008
Provider Name (Legal Business Name): CRYSTAL NURSING REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 VERA CRUZ AVE N
CRYSTAL MN
55422-2708
US

IV. Provider business mailing address

3245 VERA CRUZ AVE N
CRYSTAL MN
55422-2708
US

V. Phone/Fax

Practice location:
  • Phone: 763-971-6300
  • Fax: 763-971-6328
Mailing address:
  • Phone: 763-971-6300
  • Fax: 763-971-6328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. EPHRAM MORDY LAHASKY
Title or Position: PRESIDENT/MANAGER
Credential:
Phone: 646-772-3668