Healthcare Provider Details

I. General information

NPI: 1215191127
Provider Name (Legal Business Name): KITTSON COUNTY DEVELOPMENTAL ACHIEVEMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HILL STREET
LAKE BRONSON MN
56734
US

IV. Provider business mailing address

102 HILL STREET PO BOX 54
LAKE BRONSON MN
56734
US

V. Phone/Fax

Practice location:
  • Phone: 218-754-2225
  • Fax:
Mailing address:
  • Phone: 218-754-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number801303
License Number StateMN

VIII. Authorized Official

Name: CORRINE RAE KARBOVIAK
Title or Position: DIRECTOR
Credential:
Phone: 218-754-2225