Healthcare Provider Details

I. General information

NPI: 1124684907
Provider Name (Legal Business Name): MANKATO CHEMICAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1826 COMMERCE DR
NORTH MANKATO MN
56003-1800
US

IV. Provider business mailing address

1826 COMMERCE DR
NORTH MANKATO MN
56003-1800
US

V. Phone/Fax

Practice location:
  • Phone: 507-229-0350
  • Fax:
Mailing address:
  • Phone: 507-229-0350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: AMANDA LEE BURG
Title or Position: OWNER
Credential: LADC
Phone: 507-229-0350