Provider Demographics
NPI:1669730651
Name:COMMUNITY HEALTHCARE SERVICE
Entity type:Organization
Organization Name:COMMUNITY HEALTHCARE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:IGWILOHI
Authorized Official - Last Name:AGBATOR
Authorized Official - Suffix:
Authorized Official - Credentials:CO-OWNER
Authorized Official - Phone:612-636-3286
Mailing Address - Street 1:14249 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6738
Mailing Address - Country:US
Mailing Address - Phone:952-891-8038
Mailing Address - Fax:952-891-8038
Practice Address - Street 1:14249 HAYES RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6738
Practice Address - Country:US
Practice Address - Phone:952-891-8038
Practice Address - Fax:952-891-8038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN356758311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility