Provider Demographics
NPI:1508909730
Name:INSTITUTE FOR MINORITY DEV
Entity Type:Organization
Organization Name:INSTITUTE FOR MINORITY DEV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EX DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-566-4251
Mailing Address - Street 1:3608 78TH AVE NO
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443
Mailing Address - Country:US
Mailing Address - Phone:763-566-4251
Mailing Address - Fax:763-566-3049
Practice Address - Street 1:3608 78TH AVE NO
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443
Practice Address - Country:US
Practice Address - Phone:763-566-4251
Practice Address - Fax:763-566-3049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN805936-5-WS251S00000X
MN831150-3-SILS251S00000X
MN074522700251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN127812600Medicaid