MEDICARE: NORTHEAST HOUSE INC

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	801746-3RS	MN

General Provider Information

NPI Number	:	1962692905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST HOUSE INC

Provider Business Mailing Address
First Line	:	1918 19TH AVE NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-4728
Country	:	US
Telephone Number	:	612-789-8841
Fax Number	:

Provider Business Practice Location Address
First Line	:	1918 19TH AVE NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-4728
Country	:	US
Telephone Number	:	612-789-8841
Fax Number	:

Authorized Official
Title or Position	:	ADMIN ASSIST/PROGRAM DIR
Name	:	MR. WILLIAM L EVERETT
Credential	:	MA/QMRP/FAAMR
Telephone Number	:	612-789-8841

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	07/26/2007

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