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General NPI Number Information
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NPI Number | 1427410844
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Entity Type | Organization
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Legal Business Name | KIDSPEACE MESABI ACADEMY
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Dates
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Enumeration Date | 03/24/2016
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Last Update Date | 03/30/2016
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Provider Practice Location Address
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Address Line | 200 WANLESS STREET
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City | BUHL
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State | MN
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Zip | 55713-0726
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Country | US
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Telephone | 218-258-2274
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Fax | 218-258-2311
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Provider Business Mailing Address
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Address Line | PO BOX 726 200 WANLESS STREET
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City | BUHL
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State | MN
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Zip | 55713-0726
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Country | US
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Telephone | 218-258-2274
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Fax | 218-258-2311
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. PAUL JACOBSON
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Credential | MBA
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Telephone | 218-258-2311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1075006
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License Number State | MN
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