Healthcare Provider Details

I. General information

NPI: 1003261983
Provider Name (Legal Business Name): LAO ADVANCEMENT ORGANIZATION OF AMERICA (LAOA)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2648 W BROADWAY AVE
MINNEAPOLIS MN
55411-1004
US

IV. Provider business mailing address

2648 W BROADWAY AVE
MINNEAPOLIS MN
55411-1004
US

V. Phone/Fax

Practice location:
  • Phone: 612-302-9154
  • Fax: 612-522-2431
Mailing address:
  • Phone: 612-302-9154
  • Fax: 612-522-2431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1075697
License Number StateMN

VIII. Authorized Official

Name: DR. KHAMCHANH NMN PHANTHAVONG
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 612-302-9154