1164419057 NPI number — COKATO CHARITABLE TRUST

Table of content: (NPI 1164419057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164419057 NPI number — COKATO CHARITABLE TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COKATO CHARITABLE TRUST
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:
1164419057
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
182 SUNSET AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COKATO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55321-9620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-286-2158
Provider Business Mailing Address Fax Number:
320-286-2031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
182 SUNSET AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55321-9620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-286-2158
Provider Business Practice Location Address Fax Number:
320-286-2031
Provider Enumeration Date:
10/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MELQUIST
Authorized Official First Name:
TRESHA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
320-286-3103

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  329785 , 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: 423526600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5Z74CO . This is a "CMHH BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7111807 . This is a "CM MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9681CO . This is a "CM BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 249075700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040705008 . This is a "CM PRIME WEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 167905 . This is a "CMHH UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5900013 . This is a "CMHH MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 030802014 . This is a "CMHH PRIME WEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 30437 . This is a "CMHH HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 961043000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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