MEDICARE: GOODWILL EASTER SEALS MINNESOTA

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	:	1376759647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODWILL EASTER SEALS MINNESOTA

Provider Business Mailing Address
First Line	:	553 FAIRVIEW AVE N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-1708
Country	:	US
Telephone Number	:	651-379-5800
Fax Number	:	651-379-5804

Provider Business Practice Location Address
First Line	:	553 FAIRVIEW AVE N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-1708
Country	:	US
Telephone Number	:	651-379-5800
Fax Number	:	651-379-5804

Authorized Official
Title or Position	:	WORKFORCE DEVELOPMENT MANAGER
Name	:	BOYD A. BROWN
Credential	:
Telephone Number	:	651-379-5800

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	08/22/2020

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