Healthcare Provider Details

I. General information

NPI: 1194241166
Provider Name (Legal Business Name): FIVE STARS RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 STOUGHTON AVE.
CHASKA MN
55318
US

IV. Provider business mailing address

1045 STOUGHTON AVE.
CHASKA MN
55318
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number24D2130068
License Number State

VIII. Authorized Official

Name: JASON VANDERSCOFF
Title or Position: CEO, MANAGING DIRECTOR
Credential: LADC
Phone: 952-448-6557