Provider Demographics
NPI:1801962766
Name:KELLY-NORTON PROGRAMS, INC.
Entity type:Organization
Organization Name:KELLY-NORTON PROGRAMS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-544-1447
Mailing Address - Street 1:6739 GOLDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4618
Mailing Address - Country:US
Mailing Address - Phone:763-544-1447
Mailing Address - Fax:763-544-0833
Practice Address - Street 1:6739 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4618
Practice Address - Country:US
Practice Address - Phone:763-544-1447
Practice Address - Fax:763-544-0833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KELLY-NORTON PROGRAMS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-24
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN801798320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN128468100Medicare ID - Type UnspecifiedDHS PROVIDER ID