Provider Demographics
NPI:1679750426
Name:PRAIRIE LAKES YOUTH PROGRAMS BOYS GROUP HOME
Entity Type:Organization
Organization Name:PRAIRIE LAKES YOUTH PROGRAMS BOYS GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCGILLIVRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-235-0975
Mailing Address - Street 1:1804 CIVIC CENTER DR
Mailing Address - Street 2:PO BOX 902
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-9446
Mailing Address - Country:US
Mailing Address - Phone:320-235-0975
Mailing Address - Fax:320-214-7067
Practice Address - Street 1:1013 LAKELAND DR NE
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-2114
Practice Address - Country:US
Practice Address - Phone:320-235-6895
Practice Address - Fax:320-231-3818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1049804-1-CRF3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children