Healthcare Provider Details

I. General information

NPI: 1508939331
Provider Name (Legal Business Name): MSOCS-BLAINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12949 KENYON ST NE
MINNEAPOLIS MN
55449-4991
US

IV. Provider business mailing address

PO BOX 64979
SAINT PAUL MN
55164-0979
US

V. Phone/Fax

Practice location:
  • Phone: 763-755-0233
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: ROGER DENEEN
Title or Position: RESIDENTIAL PROG SVCS DIRECTOR
Credential:
Phone: 651-582-1857