Provider Demographics
NPI:1619374428
Name:KANABEC-PINE COMMUNITY HEALTH
Entity Type:Organization
Organization Name:KANABEC-PINE COMMUNITY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHS ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, MPH
Authorized Official - Phone:320-679-6322
Mailing Address - Street 1:905 FOREST AVE E
Mailing Address - Street 2:SUITE 127
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1624
Mailing Address - Country:US
Mailing Address - Phone:320-679-6330
Mailing Address - Fax:320-679-6333
Practice Address - Street 1:905 FOREST AVE E
Practice Address - Street 2:SUITE 127
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1624
Practice Address - Country:US
Practice Address - Phone:320-679-6330
Practice Address - Fax:320-679-6333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331159251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN471555100Medicaid
MN471555100Medicaid