Provider Demographics
NPI: | 1356439913 |
---|---|
Name: | UPPER MISSISSIPPI |
Entity Type: | Organization |
Organization Name: | UPPER MISSISSIPPI |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | BUSINESS MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KRISTI |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MILLER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 218-751-3280 |
Mailing Address - Street 1: | 722 15TH STREET NW |
Mailing Address - Street 2: | |
Mailing Address - City: | BEMIDJI |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 56619-0640 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 218-751-3280 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 722 15TH STREET NW |
Practice Address - Street 2: | |
Practice Address - City: | BEMIDJI |
Practice Address - State: | MN |
Practice Address - Zip Code: | 56619-0640 |
Practice Address - Country: | US |
Practice Address - Phone: | 218-751-3280 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-10-10 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 251B00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251B00000X | Agencies | Case Management |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | ========= | Other | MENTAL HEALTH CENTER |