Healthcare Provider Details

I. General information

NPI: 1528672243
Provider Name (Legal Business Name): ELITE CHILD DEVELOPMENT CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 MOLINA ST
SHAKOPEE MN
55379-5449
US

IV. Provider business mailing address

3860 MOLINA ST
SHAKOPEE MN
55379-5449
US

V. Phone/Fax

Practice location:
  • Phone: 612-203-3147
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM3000X
TaxonomyMedically Fragile Infants and Children Day Care
License Number
License Number State

VIII. Authorized Official

Name: HANA F DIRIE
Title or Position: OWNER
Credential:
Phone: 952-393-0559