Provider Demographics
NPI:1578808663
Name:PRAIRIE COMMUNITY SERVICES
Entity Type:Organization
Organization Name:PRAIRIE COMMUNITY SERVICES
Other - Org Name:FRESH START PCS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-589-4919
Mailing Address - Street 1:801 NEVADA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1874
Mailing Address - Country:US
Mailing Address - Phone:320-589-2004
Mailing Address - Fax:320-589-1270
Practice Address - Street 1:1610 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-1650
Practice Address - Country:US
Practice Address - Phone:218-724-2945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. FRANCIS HEALTH SERVICES OF MORRIS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-30
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNFBL-21674-37286320800000X
MN1060122-1-RMI320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness