1669424198 NPI number — COUNTY OF KANABEC

Table of content: (NPI 1669424198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669424198 NPI number — COUNTY OF KANABEC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF KANABEC
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:
1669424198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 FOREST AVE E
Provider Second Line Business Mailing Address:
SUITE. 127
Provider Business Mailing Address City Name:
MORA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55051-1624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-679-6330
Provider Business Mailing Address Fax Number:
320-679-6333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 FOREST AVE E
Provider Second Line Business Practice Location Address:
STE. 127
Provider Business Practice Location Address City Name:
MORA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55051-1624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-679-6330
Provider Business Practice Location Address Fax Number:
320-679-6333
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
320-679-6322

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , with the licence number:  331159 , 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: 471555100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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