Healthcare Provider Details

I. General information

NPI: 1144390816
Provider Name (Legal Business Name): PRAIRIE COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NEVADA AVE
MORRIS MN
56267-1865
US

IV. Provider business mailing address

801 NEVADA AVE
MORRIS MN
56267-1865
US

V. Phone/Fax

Practice location:
  • Phone: 320-589-3077
  • Fax: 320-589-2543
Mailing address:
  • Phone: 320-589-3077
  • Fax: 320-589-2543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number801779-1-RS
License Number StateMN

VIII. Authorized Official

Name: SHERRY WAGNER
Title or Position: CFO
Credential:
Phone: 320-589-4902