=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184705634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUR HOMES SOUTH, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 NORTH MAIN STREET
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55049-0119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-455-2114
-----------------------------------------------------
Fax | 507-455-2178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 119
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55049-0119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-455-2114
-----------------------------------------------------
Fax | 507-455-2178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. DENNIS KLAUS BURGESS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-455-2114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 8092892WS
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 8065272WS
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------