Healthcare Provider Details

I. General information

NPI: 1770643694
Provider Name (Legal Business Name): MARY T ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 XEON BLVD NW
COON RAPIDS MN
55448-2061
US

IV. Provider business mailing address

11800 XEON BLVD NW
COON RAPIDS MN
55448-2061
US

V. Phone/Fax

Practice location:
  • Phone: 763-754-2505
  • Fax: 763-999-1742
Mailing address:
  • Phone: 763-754-2505
  • Fax: 763-999-1742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number331577
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number801456
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number801457
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number801459
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number801458
License Number StateMN

VIII. Authorized Official

Name: DEREK MILES
Title or Position: CFO
Credential:
Phone: 763-226-3927