=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841016458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL EDGE 2 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2024
-----------------------------------------------------
Last Update Date | 11/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1979 WILSON AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55119-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-459-2724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10616 KYLE AVE N
-----------------------------------------------------
City | BROOKLYN PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55443-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-459-2724
-----------------------------------------------------
Fax | 763-208-0912
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HAJA UCHE
-----------------------------------------------------
Credential | MANAGER
-----------------------------------------------------
Telephone | 612-459-2724
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------