1588672034 NPI number — WESMAR OF INTERNATIONAL FALLS MN LLC

Table of content: MELANIE ROSE ACKER LPC (NPI 1205465739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588672034 NPI number — WESMAR OF INTERNATIONAL FALLS MN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESMAR OF INTERNATIONAL FALLS MN LLC
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:
1588672034
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 593
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
INTERNATIONAL FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56649-0593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-285-7029
Provider Business Mailing Address Fax Number:
218-285-7072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 5TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
INTERNATIONAL FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56649-2217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-285-7029
Provider Business Practice Location Address Fax Number:
218-285-7072
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUTTS
Authorized Official First Name:
WESLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
218-285-7029

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  10371421CDT , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 126613600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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