Provider Demographics
NPI:1629192430
Name:LUTHERAN SOCIAL SERVICE OF MINNESOTA
Entity Type:Organization
Organization Name:LUTHERAN SOCIAL SERVICE OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRIGID
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-310-9451
Mailing Address - Street 1:2485 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1445
Mailing Address - Country:US
Mailing Address - Phone:800-582-5260
Mailing Address - Fax:651-969-2350
Practice Address - Street 1:22 WILSON AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-0440
Practice Address - Country:US
Practice Address - Phone:320-251-7700
Practice Address - Fax:320-251-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCO1685Medicare PIN