MEDICARE: CHATTERS LUMBER 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	305S00000X	Point of Service	1069129-1-HCBS	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1069129	OTHER	MN	MN DHS LICENSE FACILITY ID

General Provider Information

NPI Number	:	1487076238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHATTERS LUMBER INC

Provider Business Mailing Address
First Line	:	4715 17TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3613
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4715 17TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3613
Country	:	US
Telephone Number	:	612-978-8191
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	GEORGE EUGENE CHATTERS
Credential	:
Telephone Number	:	612-978-8191

Provider Enumeration Date	:	01/14/2014
Last Update Date	:	01/14/2014

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