Provider Demographics
NPI:1194359547
Name:CRYSTAL WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CRYSTAL WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:ABDIQANI
Authorized Official - Last Name:NUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-658-6845
Mailing Address - Street 1:9001 E BLOOMINGTON FWY STE 147
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-3450
Mailing Address - Country:US
Mailing Address - Phone:952-658-6845
Mailing Address - Fax:612-295-0381
Practice Address - Street 1:9001 E BLOOMINGTON FWY STE 147
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-3450
Practice Address - Country:US
Practice Address - Phone:952-658-6845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-25
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health