Basic Information
| Provider Information | |||||||||
| NPI: | 1003353202 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRACARE HEALTH SYSTEM-NR LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GERIATRIC BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1013 HART BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553628575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632952945 | ||||||||
| FaxNumber: | 7632712299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1013 HART BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553628575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632952945 | ||||||||
| FaxNumber: | 7632712299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2017 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 3202555665 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
No ID Information.