- Enrollment id
- O20210129000415
- Enrollment state
- MN
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1649879941
- Multiple npi flag
- N
- Ccn
- 245289
- Associate id
- 9830503010
- Organization name
- THE TERRACE AT CRYSTAL LLC
- Incorporation date
- 2020-09-18
- Incorporation state
- MN
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- THE TERRACE AT CRYSTAL LLC
- Address line 1
- 3245 VERA CRUZ AVE N
- City
- CRYSTAL
- State
- MN
- Zip code
- 554222708