1982046132 NPI number — CENTRACARE HEALTH MONTICELLO SERVICES LLC

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 1982046132 NPI number — CENTRACARE HEALTH MONTICELLO SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRACARE HEALTH MONTICELLO SERVICES 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:
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:
1982046132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 E 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WACONIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55387-4552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-442-9770
Provider Business Mailing Address Fax Number:
952-442-3620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013 HART BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55362-8575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-295-2945
Provider Business Practice Location Address Fax Number:
952-442-3620
Provider Enumeration Date:
07/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FRIESEN
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
763-271-2303

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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