Provider Demographics
NPI:1568534576
Name:FAMILY ADVOCACY CENTER OF NORTHERN MINNESOTA
Entity Type:Organization
Organization Name:FAMILY ADVOCACY CENTER OF NORTHERN MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:218-333-6011
Mailing Address - Street 1:1300 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5103
Mailing Address - Country:US
Mailing Address - Phone:218-333-6011
Mailing Address - Fax:218-333-6113
Practice Address - Street 1:4211 MINNKOTA AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-6078
Practice Address - Country:US
Practice Address - Phone:218-444-6127
Practice Address - Fax:218-444-6129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1031751174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04183Medicare ID - Type UnspecifiedMC NUMBER