Healthcare Provider Details

I. General information

NPI: 1578796165
Provider Name (Legal Business Name): MARY'S HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 3RD ST NE
LITTLE FALLS MN
56345-2409
US

IV. Provider business mailing address

14601 LYNNDALE DR
BAXTER MN
56425-6018
US

V. Phone/Fax

Practice location:
  • Phone: 320-632-1988
  • Fax:
Mailing address:
  • Phone: 218-828-8148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number1054966-1-AFC
License Number StateMN

VIII. Authorized Official

Name: MARY JANE OLSON
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 218-828-8148