Provider Demographics
NPI:1659866630
Name:KI SENIOR LIVING OF PARK RAPIDS, LLC
Entity Type:Organization
Organization Name:KI SENIOR LIVING OF PARK RAPIDS, LLC
Other - Org Name:CRYSTAL BROOK SENIOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARNIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GUGISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-763-1164
Mailing Address - Street 1:420 12TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2612
Mailing Address - Country:US
Mailing Address - Phone:320-763-6653
Mailing Address - Fax:320-763-7548
Practice Address - Street 1:1006 CROCUS HILL ST E
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-5419
Practice Address - Country:US
Practice Address - Phone:218-699-3605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility