Healthcare Provider Details

I. General information

NPI: 1639019979
Provider Name (Legal Business Name): SPIRITS AT REST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W MAIN ST
LE ROY MN
55951-6709
US

IV. Provider business mailing address

119 W MAIN ST
LE ROY MN
55951-6709
US

V. Phone/Fax

Practice location:
  • Phone: 507-577-1415
  • Fax:
Mailing address:
  • Phone: 507-577-1415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CARL DALE WHITE
Title or Position: CEO
Credential: LICSW, LADC
Phone: 507-577-1415