Healthcare Provider Details

I. General information

NPI: 1992783955
Provider Name (Legal Business Name): CRYSTAL CARE PCA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6461 LYNDALE AVE S
RICHFIELD MN
55423-1405
US

IV. Provider business mailing address

6461 LYNDALE AVE S
RICHFIELD MN
55423-1405
US

V. Phone/Fax

Practice location:
  • Phone: 612-861-4272
  • Fax: 612-866-2290
Mailing address:
  • Phone: 612-861-4272
  • Fax: 612-866-2290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SALLY GAIL KNUTSON
Title or Position: ADMINISTRATOR
Credential: RN MA
Phone: 612-861-4272