Healthcare Provider Details

I. General information

NPI: 1992795280
Provider Name (Legal Business Name): COURAGE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/13/2007
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: 763-588-0811
  • Fax: 763-520-0237
Mailing address:
  • Phone: 763-588-0811
  • Fax: 763-520-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number8356799
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number8356799
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number8356799
License Number StateMN

VIII. Authorized Official

Name: MS. ALICE JOHNSON
Title or Position: CFO
Credential:
Phone: 763-520-0206