Provider Demographics
NPI:1710045430
Name:PROFESSIONAL RESOURCE NETWORK - PRN - CORPORATION
Entity Type:Organization
Organization Name:PROFESSIONAL RESOURCE NETWORK - PRN - CORPORATION
Other - Org Name:PROFESSIONAL RESOURCE NETWORK HOME HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEVOLITES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-858-8807
Mailing Address - Street 1:574 PRAIRIE CENTER DR STE 135-279
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7930
Mailing Address - Country:US
Mailing Address - Phone:952-858-8807
Mailing Address - Fax:
Practice Address - Street 1:4951 W 77TH ST STE 110
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4802
Practice Address - Country:US
Practice Address - Phone:952-858-8807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328388251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN611727900Medicaid
MN248054Medicare Oscar/Certification