1164627022 NPI number — SOUTH CENTRAL CRISIS CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164627022 NPI number — SOUTH CENTRAL CRISIS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CENTRAL CRISIS CENTER
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:
Provider Other Organization Name Type Code:
6
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:
1164627022
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64979
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55164-0979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-431-3676
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 PFAU ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56001-7032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-389-6872
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KORNRUMPF
Authorized Official First Name:
ROD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MENTAL HEALTH ADMIN OFFICER
Authorized Official Telephone Number:
763-712-4010

Provider Taxonomy Codes

  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 647618100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 467058206 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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