Healthcare Provider Details

I. General information

NPI: 1336658277
Provider Name (Legal Business Name): MINNESOTA TEEN CHALLENGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 ASSISI DRIVE NW
ROCHESTER MN
55901
US

IV. Provider business mailing address

740 E 24TH ST
MINNEAPILIS MN
55404
US

V. Phone/Fax

Practice location:
  • Phone: 612-373-3366
  • Fax: 612-333-4111
Mailing address:
  • Phone: 612-373-3366
  • Fax: 612-333-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DEBRA RAE WARNER
Title or Position: BILLING MANAGER
Credential:
Phone: 612-238-6528