MEDICARE: CHISAGO COUNTY COUNCIL FOR EXCEPTIONAL INDIVIDUALS, INC.

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	251C00000X	Developmentally Disabled Services Day Training Agency	8004723DTH	MN

General Provider Information

NPI Number	:	1285731646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHISAGO COUNTY COUNCIL FOR EXCEPTIONAL INDIVIDUALS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 410
Second Line	:
City	:	CHISAGO CITY
State	:	MN
Zip	:	55013-0410
Country	:	US
Telephone Number	:	651-257-6709
Fax Number	:	651-257-4904

Provider Business Practice Location Address
First Line	:	10985 LAKE BLVD.
Second Line	:
City	:	CHISAGO CITY
State	:	MN
Zip	:	55013-0410
Country	:	US
Telephone Number	:	651-257-6709
Fax Number	:	651-257-4904

Authorized Official
Title or Position	:	DIRECTOR HR
Name	:	DANIEL JOSEPH BROWN
Credential	:
Telephone Number	:	651-257-6709

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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