Provider Demographics
NPI:1750454583
Name:MSOCS-PINE CITY
Entity Type:Organization
Organization Name:MSOCS-PINE CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENTIAL PROG SVCS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-582-1857
Mailing Address - Street 1:PO BOX 64979
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55164-0979
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 6TH AVE SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1915
Practice Address - Country:US
Practice Address - Phone:320-629-2116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN MINNESOTA STATE OPERATED COMMUNITY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-17
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN823745000Medicaid