Healthcare Provider Details

I. General information

NPI: 1275679060
Provider Name (Legal Business Name): VAIL PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 9TH AVE S
HOPKINS MN
55343-7629
US

IV. Provider business mailing address

23 9TH AVE S
HOPKINS MN
55343-7629
US

V. Phone/Fax

Practice location:
  • Phone: 952-938-9622
  • Fax: 952-938-7934
Mailing address:
  • Phone: 952-938-9622
  • Fax: 952-938-7934

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
# 3
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. MICHELLE COCHRAN ZUZEK
Title or Position: DIRECTOR OF COMPLIANCE AND CONTRACT
Credential: LICSW
Phone: 952-945-4250