# STATE OF MINNESOTA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1639355902
- **Authorized official:** BRUCE J HAWKINSON (STATE PROGRAM ADMIN DIRECTOR)
- **Authorized official phone:** (507) 931-7102

## Contact information

- **Practice address:** 1111 HIGHWAY 73, MOOSE LAKE, MN 55767-9452
- **Practice address phone:** (218) 485-5300
- **Mailing address:** 400 CENTENNIAL BUILDING, 658 CEDAR STREET, SAINT PAUL, MN 55155-1616

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 323P00000X | Psychiatric Residential Treatment Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 01/16/2008
- **Last updated:** 01/16/2008