1053485904 NPI number — ATTACHMENT AND FAMILY CENTER OF MINNESOTA

Table of content: (NPI 1053485904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053485904 NPI number — ATTACHMENT AND FAMILY CENTER OF MINNESOTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATTACHMENT AND FAMILY CENTER OF MINNESOTA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY ATTACHMENT AND COUNSELING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053485904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 N CHESTNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHASKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55318-1918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-475-2818
Provider Business Mailing Address Fax Number:
952-475-3356

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 N CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHASKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55318-1918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-475-2818
Provider Business Practice Location Address Fax Number:
952-475-3356
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
TODD
Authorized Official Title or Position:
EXESCUTIVE DIRECTOR
Authorized Official Telephone Number:
952-234-4632

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 118447400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05142700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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