Provider Demographics
NPI:1073892774
Name:MINNESOTA SPECIALTY HEALTH SYSTEM CAMBRIDGE
Entity Type:Organization
Organization Name:MINNESOTA SPECIALTY HEALTH SYSTEM CAMBRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-431-3691
Mailing Address - Street 1:PO BOX 64979
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55164-0979
Mailing Address - Country:US
Mailing Address - Phone:651-431-3691
Mailing Address - Fax:651-431-7505
Practice Address - Street 1:1425 E RUM RIVER DR S
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-2569
Practice Address - Country:US
Practice Address - Phone:651-431-3691
Practice Address - Fax:651-431-7505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN804294-9-RS-N320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities