Provider Demographics
NPI:1376094847
Name:KALIS, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KALIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3545
Mailing Address - Country:US
Mailing Address - Phone:218-851-7876
Mailing Address - Fax:
Practice Address - Street 1:1102 4TH ST SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3545
Practice Address - Country:US
Practice Address - Phone:218-851-7876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1083230-1-HCBS385H00000X, 310400000X, 253J00000X
372600000X, 372500000X, 374U00000X, 376J00000X, 376K00000X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385H00000XRespite Care FacilityRespite Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide