Provider Demographics
NPI:1194421255
Name:EAST CENTRAL BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:EAST CENTRAL BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:CNP, APRN, PMHNP-BC
Authorized Official - Phone:320-223-0467
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:OGILVIE
Mailing Address - State:MN
Mailing Address - Zip Code:56358-0202
Mailing Address - Country:US
Mailing Address - Phone:320-223-0467
Mailing Address - Fax:
Practice Address - Street 1:841 FOREST AVE E STE 210
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1627
Practice Address - Country:US
Practice Address - Phone:320-244-2451
Practice Address - Fax:320-238-7497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty