Healthcare Provider Details

I. General information

NPI: 1235237199
Provider Name (Legal Business Name): FIVE STAR RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E 2ND ST SUITE 110B
CHASKA MN
55318-1966
US

IV. Provider business mailing address

102 E 2ND ST SUITE 110B
CHASKA MN
55318-1966
US

V. Phone/Fax

Practice location:
  • Phone: 952-448-6557
  • Fax: 952-448-6047
Mailing address:
  • Phone: 952-448-6557
  • Fax: 952-448-6047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON DAVID VANDERSCOFF
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 952-448-6557