Healthcare Provider Details

I. General information

NPI: 1124336862
Provider Name (Legal Business Name): PRAIRIE COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NEVADA AVE STE 100
MORRIS MN
56267-1874
US

IV. Provider business mailing address

801 NEVADA AVE STE 100
MORRIS MN
56267-1874
US

V. Phone/Fax

Practice location:
  • Phone: 320-589-2004
  • Fax: 320-589-2543
Mailing address:
  • Phone: 320-589-2004
  • Fax: 320-589-2543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number1056816
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1056816
License Number StateMN

VIII. Authorized Official

Name: SHERRY WAGNER
Title or Position: ASSIST DIRECTOR OF FINANCE
Credential:
Phone: 320-589-4902