Provider Demographics
NPI:1619379344
Name:CENTER FOR VICTIMS OF TORTURE BETHESDA -TCM
Entity Type:Organization
Organization Name:CENTER FOR VICTIMS OF TORTURE BETHESDA -TCM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:GENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-436-4869
Mailing Address - Street 1:2356 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1853
Mailing Address - Country:US
Mailing Address - Phone:612-436-4860
Mailing Address - Fax:612-436-2606
Practice Address - Street 1:580 RICE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2148
Practice Address - Country:US
Practice Address - Phone:651-227-6551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTER FOR VICTIMS OF TORTURE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN120700OtherUCARE
MNC02056Medicare PIN