Provider Demographics
NPI:1407887953
Name:COKATO CHARITABLE TRUST
Entity Type:Organization
Organization Name:COKATO CHARITABLE TRUST
Other - Org Name:COKATO MANOR HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BROICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-286-2158
Mailing Address - Street 1:182 SUNSET AVE NW
Mailing Address - Street 2:
Mailing Address - City:COKATO
Mailing Address - State:MN
Mailing Address - Zip Code:55321-9620
Mailing Address - Country:US
Mailing Address - Phone:320-286-2158
Mailing Address - Fax:320-286-2307
Practice Address - Street 1:511 COKATO ST NW
Practice Address - Street 2:
Practice Address - City:COKATO
Practice Address - State:MN
Practice Address - Zip Code:55321-9404
Practice Address - Country:US
Practice Address - Phone:320-286-3049
Practice Address - Fax:320-286-2307
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COKATO CHARITABLE TRUST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN03746251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5900013OtherMEDICA
MN030802014OtherPRIME WEST
MN249075700Medicaid
MN5Z74C0OtherBCBS
MN167905OtherUCARE
MN60-12085OtherIV THERAPY
MN30437OtherHEALTH PARTNERS
MN5Z74C0OtherBCBS