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General NPI Number Information
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NPI Number | 1962692905
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Entity Type | Organization
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Legal Business Name | NORTHEAST HOUSE INC
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Dates
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Enumeration Date | 07/26/2007
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Last Update Date | 07/26/2007
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Provider Practice Location Address
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Address Line | 1918 19TH AVE NE
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City | MINNEAPOLIS
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State | MN
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Zip | 55418-4728
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Country | US
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Telephone | 612-789-8841
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Fax |
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Provider Business Mailing Address
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Address Line | 1918 19TH AVE NE
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City | MINNEAPOLIS
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State | MN
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Zip | 55418-4728
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Country | US
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Telephone | 612-789-8841
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Fax |
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Authorized Official
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Title or Position | ADMIN ASSIST/PROGRAM DIR
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Name | MR. WILLIAM L EVERETT
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Credential | MA/QMRP/FAAMR
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Telephone | 612-789-8841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 801746-3RS
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License Number State | MN
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