Healthcare Provider Details

I. General information

NPI: 1194014134
Provider Name (Legal Business Name): MINNESOTA SPECIALITY HEALTH SYSTEMS WILLMAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 OLENA AVE. SE
WILLMAR MN
56201
US

IV. Provider business mailing address

3200 LABORE RD SUITE 104
VADNAIS HEIGHTS MN
55110-5186
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-0900
  • Fax:
Mailing address:
  • Phone: 651-539-7200
  • Fax: 651-431-7505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number1058767-1-RMI
License Number StateMN

VIII. Authorized Official

Name: LYNN GLANCEY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 651-539-7200