Provider Demographics
NPI:1811366388
Name:ISD 621
Entity Type:Organization
Organization Name:ISD 621
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-623-3363
Mailing Address - Street 1:2101 14TH ST NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2101 14TH ST NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1841
Practice Address - Country:US
Practice Address - Phone:612-623-3363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA506713800Medicaid