Provider Demographics
NPI:1871749036
Name:MERITCARE 1219
Entity type:Organization
Organization Name:MERITCARE 1219
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:70123-334-4811
Mailing Address - Street 1:1219 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3905
Mailing Address - Country:US
Mailing Address - Phone:218-846-2000
Mailing Address - Fax:
Practice Address - Street 1:1219 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3905
Practice Address - Country:US
Practice Address - Phone:218-846-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty