Healthcare Provider Details

I. General information

NPI: 1437694734
Provider Name (Legal Business Name): ERICKSON CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 129TH AVE NE
BLAINE MN
55434-3250
US

IV. Provider business mailing address

718 129TH AVE NE
BLAINE MN
55434-3250
US

V. Phone/Fax

Practice location:
  • Phone: 763-222-6562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1080489-1-HCBS
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number1080489-1-HCBS
License Number StateMN

VIII. Authorized Official

Name: LUKE ERICKSON
Title or Position: OWNER
Credential:
Phone: 763-222-6562