Provider Demographics
NPI:1295819225
Name:CRYSTAL INC
Entity Type:Organization
Organization Name:CRYSTAL INC
Other - Org Name:KAREN ACRES HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-223-0758
Mailing Address - Street 1:3605 ELM DR
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-3019
Mailing Address - Country:US
Mailing Address - Phone:515-276-4969
Mailing Address - Fax:515-276-6612
Practice Address - Street 1:3605 ELM DR
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-3019
Practice Address - Country:US
Practice Address - Phone:515-276-4969
Practice Address - Fax:515-276-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA770275314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0808824Medicaid
IA165460Medicare Oscar/Certification