Healthcare Provider Details

I. General information

NPI: 1336460518
Provider Name (Legal Business Name): POR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8441 WAYZATA BLVD STE 103
GOLDEN VALLEY MN
55426-1349
US

IV. Provider business mailing address

14329 ALLEN DR
SAVAGE MN
55378-2230
US

V. Phone/Fax

Practice location:
  • Phone: 952-835-6540
  • Fax:
Mailing address:
  • Phone: 612-221-2441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES W KEENAN
Title or Position: CEO
Credential: MS, LP
Phone: 612-221-2441