Healthcare Provider Details

I. General information

NPI: 1912283334
Provider Name (Legal Business Name): NEW DIRECTIONS FOR CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 BROOKLYN BLVD - LOWER LEVEL
BROOKLYN CENTER MN
55429
US

IV. Provider business mailing address

6500 BROOKLYN BLVD STE 103
BROOKLYN CENTER MN
55429-1755
US

V. Phone/Fax

Practice location:
  • Phone: 612-414-4814
  • Fax: 952-938-5014
Mailing address:
  • Phone: 612-414-4814
  • Fax: 952-938-5014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MR. ARLAND P FANNING
Title or Position: TREATMENT DIRECTOR
Credential:
Phone: 612-414-4814