MEDICARE: CRYSTAL SEASONS ALF 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	:	1992183461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL SEASONS ALF LLC

Provider Business Mailing Address
First Line	:	4044 GREENWOOD ST
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-1942
Country	:	US
Telephone Number	:	516-410-5209
Fax Number	:

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	:	516-410-5209
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JOSH LEGUM
Credential	:
Telephone Number	:	516-410-5209

Provider Enumeration Date	:	05/15/2015
Last Update Date	:	05/15/2015

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