Organization
ISD 621
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOYCE ELLEFSON (COORDINATOR)
(612) 623-3363
Entity
Organization
Contact information
Practice address
2101 14TH ST NW, NEW BRIGHTON, MN 55112-1841
(612) 623-3363
Mailing address
2101 14TH ST NW, NEW BRIGHTON, MN 55112-1841
Taxonomy
Speciality
Code
Description
License number
State
332U00000X
Home Delivered Meals
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
A506713800
—
MN
Enumeration date
09/15/2015
Last updated
09/15/2015
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