Provider Demographics
NPI:1003944620
Name:CATHOLIC CHARITIES OF THE DIOCESE OF ST. CLOUD
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES OF THE DIOCESE OF ST. CLOUD
Other - Org Name:HOPE - WAIVERED
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-650-1545
Mailing Address - Street 1:PO BOX 2390
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-2390
Mailing Address - Country:US
Mailing Address - Phone:320-650-1550
Mailing Address - Fax:320-650-1510
Practice Address - Street 1:157 ROOSEVELT RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-5478
Practice Address - Country:US
Practice Address - Phone:320-240-3324
Practice Address - Fax:320-240-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN936315701Medicaid