Healthcare Provider Details

I. General information

NPI: 1649403643
Provider Name (Legal Business Name): POLK COUNTY SOCIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N BROADWAY STE 110
CROOKSTON MN
56716-1452
US

IV. Provider business mailing address

612 N BROADWAY STE 110
CROOKSTON MN
56716-1452
US

V. Phone/Fax

Practice location:
  • Phone: 218-281-3127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. KENT JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 218-470-8405