Provider Demographics
NPI:1609473321
Name:INDEPENDENT LIVING SERVICES OF CENTRAL MINNESOTA
Entity Type:Organization
Organization Name:INDEPENDENT LIVING SERVICES OF CENTRAL MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DESIGNATED COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:CORENE
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-828-7474
Mailing Address - Street 1:1637 4TH AVE N STE 101
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2782
Mailing Address - Country:US
Mailing Address - Phone:320-828-7474
Mailing Address - Fax:320-323-1177
Practice Address - Street 1:1637 4TH AVE N STE 101
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-2782
Practice Address - Country:US
Practice Address - Phone:320-828-7474
Practice Address - Fax:320-323-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care