Healthcare Provider Details

I. General information

NPI: 1336473560
Provider Name (Legal Business Name): OPTIONS RESIDENTIAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 09/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 DUPONT AVE S
BLOOMINGTON MN
55431-3139
US

IV. Provider business mailing address

2105 W BURNSVILLE PKWY
BURNSVILLE MN
55337-4237
US

V. Phone/Fax

Practice location:
  • Phone: 952-564-3030
  • Fax:
Mailing address:
  • Phone: 952-564-3030
  • Fax: 952-564-3038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number1052266-1-AFC
License Number StateMN

VIII. Authorized Official

Name: MR. BRIAN P SAMMON
Title or Position: PRESIDENT
Credential: LADC, LMFT
Phone: 612-226-7120