MEDICARE: CRYSTAL SEASONS LIVING COMMUNITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1598912917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL SEASONS LIVING COMMUNITY

Provider Business Mailing Address
First Line	:	PO BOX 1236
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56002-1236
Country	:	US
Telephone Number	:	507-625-8741
Fax Number	:	507-387-4838

Provider Business Practice Location Address
First Line	:	222 S MURPHY ST
Second Line	:
City	:	LAKE CRYSTAL
State	:	MN
Zip	:	56055-2128
Country	:	US
Telephone Number	:	507-726-2266
Fax Number	:	507-726-2276

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHRISTOPHER THRO
Credential	:
Telephone Number	:	507-625-8741

Provider Enumeration Date	:	08/27/2008
Last Update Date	:	08/27/2008

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Directions to “CRYSTAL SEASONS LIVING COMMUNITY ” Practice Location

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