Healthcare Provider Details

I. General information

NPI: 1922231695
Provider Name (Legal Business Name): ROSEAU COUNTY COMMITTEE ON AGING
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

215 MAIN AVE S
ROSEAU MN
56751-1422
US

IV. Provider business mailing address

PO BOX 189 215 SOUTH MAIN
ROSEAU MN
56751-0189
US

V. Phone/Fax

Practice location:
  • Phone: 218-463-3177
  • Fax: 218-463-0001
Mailing address:
  • Phone: 218-463-3177
  • Fax: 218-463-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateMN

VIII. Authorized Official

Name: MRS. GAYLE RUTH GUSTAFSON
Title or Position: COORDINATOR
Credential:
Phone: 218-463-3177