Healthcare Provider Details

I. General information

NPI: 1821124447
Provider Name (Legal Business Name): SHERIFFS YOUTH PROGRAMS OF MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 BUCKLEY WAY
INVER GROVE HEIGHTS MN
55076-2018
US

IV. Provider business mailing address

2925 BUCKLEY WAY
INVER GROVE HEIGHTS MN
55076-2018
US

V. Phone/Fax

Practice location:
  • Phone: 651-552-5742
  • Fax: 651-552-5741
Mailing address:
  • Phone: 651-552-5742
  • Fax: 651-552-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number806195-3-CRF
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number1042569-1-CRF
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License NumberDOC LIC FOR VOC SKIL
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number1036867-1-CRF
License Number StateMN

VIII. Authorized Official

Name: MR. STEVEN RICHARD HUBBARD
Title or Position: CEO
Credential: MSW
Phone: 651-552-5742