Basic Information
Provider Information | |||||||||
NPI: | 1659459774 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRAIRIE COMMINITY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 NEVADA AVE | ||||||||
Address2: |   | ||||||||
City: | MORRIS | ||||||||
State: | MN | ||||||||
PostalCode: | 562671865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3205893077 | ||||||||
FaxNumber: | 3205892543 | ||||||||
Practice Location | |||||||||
Address1: | 801 NEVADA AVE | ||||||||
Address2: |   | ||||||||
City: | MORRIS | ||||||||
State: | MN | ||||||||
PostalCode: | 562671865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3205893077 | ||||||||
FaxNumber: | 3205892543 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2006 | ||||||||
LastUpdateDate: | 03/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WAGNER | ||||||||
AuthorizedOfficialFirstName: | SHERRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3205894902 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 808635-1-RS | MN | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
ID Information
ID | Type | State | Issuer | Description | 1133250000 | 05 | MN |   | MEDICAID |