1477854289 NPI number — REM HEARTLAND, INC.

Table of content: (NPI 1477854289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477854289 NPI number — REM HEARTLAND, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REM HEARTLAND, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
REM HEARTLAND, INC. ODYSSEY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477854289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6600 FRANCE AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-922-6776
Provider Business Mailing Address Fax Number:
952-922-6885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 VICTORIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56031-4453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-922-6776
Provider Business Practice Location Address Fax Number:
952-922-6885
Provider Enumeration Date:
11/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
BRET
Authorized Official Middle Name:
IAN
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
800-388-5150

Provider Taxonomy Codes

  • Taxonomy code: 3104A0625X , with the licence number:  803838-2-WS , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 803838-2-WS , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: UNKNOWN . This is a "CERTIFICATE OF REGISTRACTION MN DEPARTMENT OF HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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