MEDICARE: NORTHERN PINES MENTAL HEALTH CENTER, INC.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	1001061CDT	MN
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	10102841CDT	MN
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	8017541MHC	MN

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	126039	OTHER	MN	UCARE MINNESOTA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	4788N0	OTHER	MN	BCBS OF MINNESOTA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	6369	OTHER	MN	HEALTH PARTNERS
6	83367N0	OTHER	MN	BCBS OF MINNESOTA
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	98224	OTHER	MN	PREFERRED ONE

NPI Number	:	1013904051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN PINES MENTAL HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 367
Second Line	:	1906 5TH AVE SE
City	:	LITTLE FALLS
State	:	MN
Zip	:	56345-0367
Country	:	US
Telephone Number	:	320-632-6642
Fax Number	:	320-632-9525

Provider Business Practice Location Address
First Line	:	1906 5TH AVE SE
Second Line	:
City	:	LITTLE FALLS
State	:	MN
Zip	:	56345-3317
Country	:	US
Telephone Number	:	320-632-6647
Fax Number	:	320-632-9525

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LAURA VAUGHN
Credential	:
Telephone Number	:	320-639-2025

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	09/24/2024

2500 E 52ND ST N , CIGNA MEDICARE SERVICES
SIOUX FALLS, SD
57104-7106

Practice Phone: 605-373-0100
Practice Fax: