Provider Demographics
NPI:1346598547
Name:PROFESSIONAL RESOURCE NETWORK, INC
Entity Type:Organization
Organization Name:PROFESSIONAL RESOURCE NETWORK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEVOLITES
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MSHCA
Authorized Official - Phone:952-858-8827
Mailing Address - Street 1:2740 AMERICAN BLVD W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1203
Mailing Address - Country:US
Mailing Address - Phone:952-858-8827
Mailing Address - Fax:952-858-8835
Practice Address - Street 1:2740 AMERICAN BLVD W
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1203
Practice Address - Country:US
Practice Address - Phone:952-858-8827
Practice Address - Fax:952-858-8835
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL RESOURCE NETWORK, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1710045430Medicaid