Basic Information
| Provider Information | |||||||||
| NPI: | 1124336862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRAIRIE COMMUNITY SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRENTWOOD PCS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 NEVADA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205892004 | ||||||||
| FaxNumber: | 3205892543 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 NEVADA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205892004 | ||||||||
| FaxNumber: | 3205892543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2010 | ||||||||
| LastUpdateDate: | 04/19/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSIST DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3205894902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1056816 | MN | N | Agencies | Community/Behavioral Health | 320800000X | 1056816 | MN | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 1124336862 | 05 | MN | MEDICAID |