Basic Information
| Provider Information | |||||||||
| NPI: | 1093278764 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANFORD HEALTH OF NORTHERN MINNESOTA | ||||||||
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| OtherOrganizationName: | SANFORD HEALTH PRIMEWEST RESIDENTIAL SUPPORT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3124 HANNAH AVE NW | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566015625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183332300 | ||||||||
| FaxNumber: | 2183330317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2019 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6053288380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANFORD | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 276400000X | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.