1003848375 NPI number — CENTERWELL CERTIFIED HEALTHCARE CORP.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003848375 NPI number — CENTERWELL CERTIFIED HEALTHCARE CORP.

Employer Identification Number (EIN):

Provider Organization Name:

CENTERWELL CERTIFIED HEALTHCARE CORP.

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

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:

1003848375

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

10/14/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6330 SPRINT PKWY STE 300

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

OVERLAND PARK

Provider Business Mailing Address State Name:

KS

Provider Business Mailing Address Postal Code:

66211-1157

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

11 E SUPERIOR ST STE 508

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

DULUTH

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

55802-3014

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

218-723-8999

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

07/07/2006

Authorized Official Last Name:

NICHOLS

Authorized Official First Name:

JOHN

Authorized Official Middle Name:

Authorized Official Title or Position:

AUTHORIZED OFFICIAL

Authorized Official Telephone Number:

218-723-8999

• Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 169027 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 247241 . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 4117KI , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 5900031 . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: GA0785 . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 169027 . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 013100P . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 023355200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 4117KI . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 991234 . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: ANC015 . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 5900031 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 109673 . This is a "MN-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".