Healthcare Provider Details

I. General information

NPI: 1154977056
Provider Name (Legal Business Name): MINNESOTA TEEN CHALLENGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2756 DOUGLAS DR N
CRYSTAL MN
55422-2402
US

IV. Provider business mailing address

740 E 24TH ST
MINNEAPOLIS MN
55404-3862
US

V. Phone/Fax

Practice location:
  • Phone: 612-373-3366
  • Fax:
Mailing address:
  • Phone: 763-257-5301
  • Fax: 763-322-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SADIE TWITE
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 612-373-3366