Provider Demographics
NPI:1972590933
Name:SOUTHEASTERN MINNESOTA CENTER FOR INDEPENDENT LIVING
Entity Type:Organization
Organization Name:SOUTHEASTERN MINNESOTA CENTER FOR INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLE MOLLE
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:507-285-3912
Mailing Address - Street 1:2720 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-3980
Mailing Address - Country:US
Mailing Address - Phone:507-285-1815
Mailing Address - Fax:507-288-8070
Practice Address - Street 1:2720 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-3980
Practice Address - Country:US
Practice Address - Phone:507-285-1815
Practice Address - Fax:507-288-8070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health