Healthcare Provider Details

I. General information

NPI: 1407356710
Provider Name (Legal Business Name): REFRACTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22575 43RD AVE
SAINT AUGUSTA MN
56301-8729
US

IV. Provider business mailing address

22575 43RD AVE
SAINT AUGUSTA MN
56301-8729
US

V. Phone/Fax

Practice location:
  • Phone: 320-223-1161
  • Fax:
Mailing address:
  • Phone: 320-223-1161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number00597
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MOLLY CORENE PENA
Title or Position: OWNER
Credential:
Phone: 320-252-6017