Provider Demographics
NPI:1447801303
Name:MINNESOTA ODD FELLOWS HOME
Entity Type:Organization
Organization Name:MINNESOTA ODD FELLOWS HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:PIZINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-664-8800
Mailing Address - Street 1:815 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-1643
Mailing Address - Country:US
Mailing Address - Phone:507-664-8800
Mailing Address - Fax:507-664-8902
Practice Address - Street 1:815 FOREST AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-1643
Practice Address - Country:US
Practice Address - Phone:507-664-8865
Practice Address - Fax:507-650-9227
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA ODD FELLOWS HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA315442300Medicaid