Provider Demographics
NPI:1942327432
Name:CATHOLIC CHARITIES OF THE DIOCESE OF ST CLOUD
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES OF THE DIOCESE OF ST CLOUD
Other - Org Name:SILS-WAIVERED
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROSCHOFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-650-1571
Mailing Address - Street 1:PO BOX 2390
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-2390
Mailing Address - Country:US
Mailing Address - Phone:320-650-1550
Mailing Address - Fax:320-650-1528
Practice Address - Street 1:1730 7TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-5711
Practice Address - Country:US
Practice Address - Phone:320-240-3337
Practice Address - Fax:320-240-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN936315700Medicaid