Provider Demographics
NPI:1598853533
Name:SOUTH METRO HUMAN SERVICES
Entity Type:Organization
Organization Name:SOUTH METRO HUMAN SERVICES
Other - Org Name:COMMUNITY FOUNDATIONS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-256-1234
Mailing Address - Street 1:1096 GERVIS AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109
Mailing Address - Country:US
Mailing Address - Phone:651-221-9880
Mailing Address - Fax:651-225-1545
Practice Address - Street 1:1096 GERVAIS AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1909
Practice Address - Country:US
Practice Address - Phone:651-221-9880
Practice Address - Fax:651-225-1545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN801654-1-RMI320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN355499600Medicaid