Provider Demographics
NPI:1104098672
Name:TRI-VALLEY OPPORTUNITY COUNCIL
Entity type:Organization
Organization Name:TRI-VALLEY OPPORTUNITY COUNCIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:218-281-5832
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-0607
Mailing Address - Country:US
Mailing Address - Phone:218-281-5832
Mailing Address - Fax:218-281-6676
Practice Address - Street 1:102 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1731
Practice Address - Country:US
Practice Address - Phone:218-281-5832
Practice Address - Fax:218-281-6676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR137745-7251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare