Provider Demographics
NPI:1194757468
Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Entity type:Organization
Organization Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-636-6330
Mailing Address - Street 1:6330 SPRINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7101 NORTHLAND CIR N STE 101
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-1517
Practice Address - Country:US
Practice Address - Phone:763-416-0289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
071755000OtherMN-COMMERCIAL NUMBER
109673OtherMN-COMMERCIAL NUMBER
MN169027Medicaid
565732OtherMN-COMMERCIAL NUMBER
MN071755000Medicaid
169027OtherMN-COMMERCIAL NUMBER
MN41525000Medicaid
41532800OtherMN-COMMERCIAL NUMBER
106825087OtherMN-COMMERCIAL NUMBER
247145OtherMN-COMMERCIAL NUMBER
WI41525000Medicaid
MN5900033Medicaid
113414024DOtherMN-COMMERCIAL NUMBER
5900031OtherMN-COMMERCIAL NUMBER
013100POtherMN-COMMERCIAL NUMBER
4614OLOtherMN-COMMERCIAL NUMBER
MN4614OLMedicaid
5900033OtherMN-COMMERCIAL NUMBER
MN4614OLMedicaid
MN169027Medicaid