Healthcare Provider Details

I. General information

NPI: 1821584657
Provider Name (Legal Business Name): AMAZING GRACE RECOVERY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 07/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23671 SAINT FRANCIS BLVD NW
SAINT FRANCIS MN
55070-9802
US

IV. Provider business mailing address

35619 HELIUM ST NW
PRINCETON MN
55371-4791
US

V. Phone/Fax

Practice location:
  • Phone: 651-343-3670
  • Fax:
Mailing address:
  • Phone: 651-343-3670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1093306
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1093306
License Number StateMN

VIII. Authorized Official

Name: MICHAEL LEADENS
Title or Position: PRESIDENT/CEO
Credential: MA, LADC
Phone: 651-343-3670