MEDICARE: KOOCHICHING COUNTY COMMUNITY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	5711893	MN

General Provider Information

NPI Number	:	1104150291
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOOCHICHING COUNTY COMMUNITY SERVICES

Provider Business Mailing Address
First Line	:	1000 5TH ST
Second Line	:
City	:	INTL FALLS
State	:	MN
Zip	:	56649-2243
Country	:	US
Telephone Number	:
Fax Number	:	218-283-7013

Provider Business Practice Location Address
First Line	:	1000 5TH ST
Second Line	:
City	:	INTL FALLS
State	:	MN
Zip	:	56649-2243
Country	:	US
Telephone Number	:	218-283-7000
Fax Number	:	218-283-7013

Authorized Official
Title or Position	:	ACCOUNTING TECHNICIAN
Name	:	BOBBI SIVONEN
Credential	:
Telephone Number	:	218-283-7000

Provider Enumeration Date	:	09/23/2009
Last Update Date	:	02/25/2010

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