Provider Demographics
NPI:1013374008
Name:CRYSTAL NURSING REHABILITATION, LLC
Entity Type:Organization
Organization Name:CRYSTAL NURSING REHABILITATION, LLC
Other - Org Name:CENTENNIAL GARDENS FOR NURSING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:EPHRAM
Authorized Official - Middle Name:MORDY
Authorized Official - Last Name:LAHASKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-772-3668
Mailing Address - Street 1:3245 VERA CRUZ AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2708
Mailing Address - Country:US
Mailing Address - Phone:763-971-6300
Mailing Address - Fax:763-971-6328
Practice Address - Street 1:3245 VERA CRUZ AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55422-2708
Practice Address - Country:US
Practice Address - Phone:763-971-6300
Practice Address - Fax:763-971-6328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility