Provider Demographics
NPI:1528011210
Name:CRYSTAL PROPERTIES INC.
Entity Type:Organization
Organization Name:CRYSTAL PROPERTIES INC.
Other - Org Name:PLEASANT PARK ESTATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
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 1:1514 HIGH AVE W
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-1944
Mailing Address - Country:US
Mailing Address - Phone:641-673-7032
Mailing Address - Fax:641-673-7723
Practice Address - Street 1:1514 HIGH AVE W
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-1944
Practice Address - Country:US
Practice Address - Phone:641-673-7032
Practice Address - Fax:641-673-7723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA620049314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI-0809772Medicaid
IA620049OtherSTATE LICENSE NUMBER
IA16E722OtherSTATE DIA NUMBER
IAI-0809772Medicaid