1831386275 NPI number — CENTRAL MINNESOTA MENTAL HEALTH CENTER

Table of content: (NPI 1831386275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831386275 NPI number — CENTRAL MINNESOTA MENTAL HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL MINNESOTA MENTAL HEALTH 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:
1831386275
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1321 13TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-2613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-252-5010
Provider Business Mailing Address Fax Number:
320-203-1855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
380 ANNANDALE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNANDALE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-274-4050
Provider Business Practice Location Address Fax Number:
320-274-4069
Provider Enumeration Date:
10/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BARAGA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
320-252-5010

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  FBL-0020515-25193 , 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: FBL-0020515-25193 . This is a "DEPART OF HEALTH LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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