MEDICARE: CRESCENT CARE LLC

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	:	1679401046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESCENT CARE LLC

Provider Business Mailing Address
First Line	:	13415 54TH AVE N
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55442-1767
Country	:	US
Telephone Number	:	763-998-6184
Fax Number	:

Provider Business Practice Location Address
First Line	:	13415 54TH AVE N
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55442-1767
Country	:	US
Telephone Number	:	763-998-6184
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CUBAYDULAH NORIDIN ABDULKADIR
Credential	:
Telephone Number	:	612-232-9237

Provider Enumeration Date	:	05/13/2026
Last Update Date	:	05/13/2026

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