MEDICARE: EVELETH MENTAL HEALTH SERVICES SOCS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	283Q00000X	Psychiatric Hospital	330994	MN

General Provider Information

NPI Number	:	1013954460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVELETH MENTAL HEALTH SERVICES SOCS

Provider Business Mailing Address
First Line	:	PO BOX 64979
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55164-0979
Country	:	US
Telephone Number	:	651-431-3676
Fax Number	:

Provider Business Practice Location Address
First Line	:	227 MCKINLEY AVE
Second Line	:
City	:	EVELETH
State	:	MN
Zip	:	55734-1606
Country	:	US
Telephone Number	:	218-485-5000
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH ADMIN OFFICER
Name	:	MR. ROD L KORNRUMPF
Credential	:
Telephone Number	:	763-712-4010

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	08/22/2020

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