MEDICARE: EAST SIDE NEIGHBORHOOD 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	251K00000X	Public Health or Welfare Agency

General Provider Information

NPI Number	:	1528575149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST SIDE NEIGHBORHOOD SERVICES

Provider Business Mailing Address
First Line	:	1700 2ND ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-1139
Country	:	US
Telephone Number	:	612-781-6011
Fax Number	:	612-787-4018

Provider Business Practice Location Address
First Line	:	1700 2ND ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-1139
Country	:	US
Telephone Number	:	612-781-6011
Fax Number	:	612-787-4018

Authorized Official
Title or Position	:	CFO
Name	:	MR. JEFFREY MUNDINGER
Credential	:
Telephone Number	:	612-781-6011

Provider Enumeration Date	:	01/04/2018
Last Update Date	:	01/04/2018

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