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General NPI Number Information
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NPI Number | 1871700765
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Entity Type | Organization
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Legal Business Name | CROSSROAD LANDING INC
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 502 GLENWOOD AVE
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City | CLOQUET
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State | MN
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Zip | 55720-1208
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Country | US
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Telephone | 218-499-4030
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Fax | 952-400-8950
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Provider Business Mailing Address
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Address Line | 502 GLENWOOD AVE
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City | CLOQUET
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State | MN
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Zip | 55720-1208
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Country | US
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Telephone | 218-499-4030
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Fax | 952-400-8950
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DENNIS ERVIN ELLEFSON
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Credential |
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Telephone | 218-499-4030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 1047494-1-AFC
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License Number State | MN
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