Healthcare Provider Details

I. General information

NPI: 1831376680
Provider Name (Legal Business Name): PRAIRIE LAKES YOUTH PROGRAMS GIRLS GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 PARK AVE
WILLMAR MN
56201-2568
US

IV. Provider business mailing address

1804 CIVIC CENTER DR PO BOX 902
WILLMAR MN
56201-9446
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-6637
  • Fax: 320-235-6659
Mailing address:
  • Phone: 320-235-0975
  • Fax: 320-214-7067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number1049805-1-CRF
License Number StateMN

VIII. Authorized Official

Name: JOYCE K. MCGILLIVRAY
Title or Position: ACCOUNTS MANAGER
Credential:
Phone: 320-235-0975