=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528672243
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE CHILD DEVELOPMENT CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2020
-----------------------------------------------------
Last Update Date | 09/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3860 MOLINA ST
-----------------------------------------------------
City | SHAKOPEE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55379-5449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-203-3147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3860 MOLINA ST
-----------------------------------------------------
City | SHAKOPEE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55379-5449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HANA F DIRIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-393-0559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM3000X
-----------------------------------------------------
Taxonomy Name | Medically Fragile Infants and Children Day Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------