MEDICARE: PROGRESSIVE INDIVIDUAL RESOURCES II

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1255656161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESSIVE INDIVIDUAL RESOURCES II

Provider Business Mailing Address
First Line	:	220 ROBERT ST S STE 200
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55107-1692
Country	:	US
Telephone Number	:	612-749-3309
Fax Number	:	651-222-6567

Provider Business Practice Location Address
First Line	:	220 ROBERT ST S STE 200
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55107-1692
Country	:	US
Telephone Number	:	612-749-3309
Fax Number	:	651-222-6567

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. RICHARD BOLADE ONI
Credential	:	PHD, LISW
Telephone Number	:	612-749-3309

Provider Enumeration Date	:	04/03/2010
Last Update Date	:	04/03/2010

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