Healthcare Provider Details

I. General information

NPI: 1588716203
Provider Name (Legal Business Name): COURAGE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55422-4249
US

IV. Provider business mailing address

3915 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55422-4249
US

V. Phone/Fax

Practice location:
  • Phone: 612-588-0811
  • Fax: 763-520-0237
Mailing address:
  • Phone: 612-588-0811
  • Fax: 763-520-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number8356799
License Number StateMN

VIII. Authorized Official

Name: NANCY CARLSON
Title or Position: CHRONIC PAIN PROGRAM DIRECTOR
Credential:
Phone: 763-520-0261