Provider Demographics
NPI:1639355902
Name:STATE OF MINNESOTA
Entity Type:Organization
Organization Name:STATE OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE PROGRAM ADMIN DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAWKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-931-7102
Mailing Address - Street 1:400 CENTENNIAL BUILDING
Mailing Address - Street 2:658 CEDAR STREET
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55155-1616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 HIGHWAY 73
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9452
Practice Address - Country:US
Practice Address - Phone:218-485-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility