Healthcare Provider Details

I. General information

NPI: 1376733659
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICE OF MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 EICKHOF BLVD KAIROS HOUSE
CROOKSTON MN
56716-2600
US

IV. Provider business mailing address

2485 COMO AVE
SAINT PAUL MN
55108-1445
US

V. Phone/Fax

Practice location:
  • Phone: 218-281-1524
  • Fax:
Mailing address:
  • Phone: 800-582-5260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BRIGID PETERSON
Title or Position: CONTROLLER
Credential:
Phone: 800-582-5260