Basic Information
| Provider Information | |||||||||
| NPI: | 1578808663 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRAIRIE COMMUNITY SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FRESH START PCS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 NEVADA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205892004 | ||||||||
| FaxNumber: | 3205891270 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558121650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187242945 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2012 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3205894919 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 1060122-1-RMI | MN | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 320800000X | FBL-21674-37286 | MN | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.