Provider Demographics
NPI:1831215128
Name:OTTER TAIL WADENA COMMUNITY ACTION COUNCIL
Entity type:Organization
Organization Name:OTTER TAIL WADENA COMMUNITY ACTION COUNCIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC. DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEINO-MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-385-2900
Mailing Address - Street 1:PO BOX L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:MN
Mailing Address - Zip Code:56567-0372
Mailing Address - Country:US
Mailing Address - Phone:218-385-2900
Mailing Address - Fax:218-385-4544
Practice Address - Street 1:200 1ST AVE S
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1445
Practice Address - Country:US
Practice Address - Phone:218-346-3612
Practice Address - Fax:218-346-3612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN587053400Medicaid