Basic Information
| Provider Information | |||||||||
| NPI: | 1598912917 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRYSTAL SEASONS LIVING COMMUNITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1236 | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076258741 | ||||||||
| FaxNumber: | 5073874838 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 S MURPHY ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CRYSTAL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560552128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5077262266 | ||||||||
| FaxNumber: | 5077262276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 08/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | THRO | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5076258741 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE THRO COMPANY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.