MEDICARE: LAKE AUTISM CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1639927239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE AUTISM CENTER INC

Provider Business Mailing Address
First Line	:	1330 LAGOON AVE STE 425
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2885
Country	:	US
Telephone Number	:	952-200-3684
Fax Number	:

Provider Business Practice Location Address
First Line	:	1330 LAGOON AVE STE 425
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2885
Country	:	US
Telephone Number	:	952-200-3684
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AMINA MOHAMUD MOHAMED
Credential	:
Telephone Number	:	952-200-3664

Provider Enumeration Date	:	05/08/2024
Last Update Date	:	05/08/2024

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