Healthcare Provider Details

I. General information

NPI: 1649963109
Provider Name (Legal Business Name): WHITEMOUNTAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7133 116TH PL N
CHAMPLIN MN
55316-2879
US

IV. Provider business mailing address

7133 116TH PL N
CHAMPLIN MN
55316-2879
US

V. Phone/Fax

Practice location:
  • Phone: 612-483-3771
  • Fax:
Mailing address:
  • Phone: 612-483-3771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: TITILOPE AKANO
Title or Position: PRESIDENT
Credential:
Phone: 612-251-2366