=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710045430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL RESOURCE NETWORK - PRN - CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 11/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4951 W 77TH ST STE 110
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-858-8807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 574 PRAIRIE CENTER DR STE 135-279
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55344-7930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-858-8807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHARIE L DEVOLITES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-858-8807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 328388
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------