Healthcare Provider Details

I. General information

NPI: 1043754757
Provider Name (Legal Business Name): CATHOLIC CHARITIES OF THE DIOCESE OF ST. CLOUD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1726 7TH AVE S
SAINT CLOUD MN
56301-5711
US

IV. Provider business mailing address

911 18TH ST N
SAINT CLOUD MN
56303-1203
US

V. Phone/Fax

Practice location:
  • Phone: 320-650-1500
  • Fax: 320-650-1508
Mailing address:
  • Phone: 320-650-1550
  • Fax: 320-650-1528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number80388912CRF
License Number StateMN

VIII. Authorized Official

Name: STEPHEN R. PAREJA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 320-650-1550