Provider Demographics
NPI:1730413915
Name:PINE COUNTY HUMAN SERVICES
Entity type:Organization
Organization Name:PINE COUNTY HUMAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-216-4108
Mailing Address - Street 1:130 ORIOLE ST E
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-5156
Mailing Address - Country:US
Mailing Address - Phone:320-216-4100
Mailing Address - Fax:320-216-4101
Practice Address - Street 1:130 ORIOLE ST E
Practice Address - Street 2:SUITE 1
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-5156
Practice Address - Country:US
Practice Address - Phone:320-216-4100
Practice Address - Fax:320-216-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA000058200Medicaid