Provider Demographics
NPI:1871700765
Name:CROSSROAD LANDING INC
Entity type:Organization
Organization Name:CROSSROAD LANDING INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:ERVIN
Authorized Official - Last Name:ELLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-499-4030
Mailing Address - Street 1:502 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1208
Mailing Address - Country:US
Mailing Address - Phone:218-499-4030
Mailing Address - Fax:952-400-8950
Practice Address - Street 1:502 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1208
Practice Address - Country:US
Practice Address - Phone:218-499-4030
Practice Address - Fax:952-400-8950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1047494-1-AFC311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home