Provider Demographics
NPI:1891735627
Name:CRYSTAL CARE SUPPORT SERVICES, INC
Entity Type:Organization
Organization Name:CRYSTAL CARE SUPPORT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MA
Authorized Official - Phone:612-861-4272
Mailing Address - Street 1:6461 LYNDALE AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1405
Mailing Address - Country:US
Mailing Address - Phone:612-861-4272
Mailing Address - Fax:612-866-2290
Practice Address - Street 1:6461 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1405
Practice Address - Country:US
Practice Address - Phone:612-861-4272
Practice Address - Fax:612-866-2290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21157251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN21157OtherCLASS A LICENSE