MEDICARE: VALLEY-LAKE BOY'S HOME, 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	1036970-1-CRF	MN

General Provider Information

NPI Number	:	1760666903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALLEY-LAKE BOY'S HOME, INC.

Provider Business Mailing Address
First Line	:	3850 200TH AVE
Second Line	:
City	:	BRECKENRIDGE
State	:	MN
Zip	:	56520-0411
Country	:	US
Telephone Number	:	218-643-4036
Fax Number	:	218-643-5226

Provider Business Practice Location Address
First Line	:	3850 200TH AVE
Second Line	:
City	:	BRECKENRIDGE
State	:	MN
Zip	:	56520-0411
Country	:	US
Telephone Number	:	218-643-4036
Fax Number	:	218-643-5226

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MARK ALLEN ENGEBRETSON
Credential	:
Telephone Number	:	218-643-4036

Provider Enumeration Date	:	12/24/2007
Last Update Date	:	12/24/2007

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