Healthcare Provider Details

I. General information

NPI: 1215662499
Provider Name (Legal Business Name): AMETHYST RECOVERY HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 WINSLOW AVE
SAINT PAUL MN
55107-3349
US

IV. Provider business mailing address

5862 BURKE TRL
INVER GROVE HEIGHTS MN
55076-1583
US

V. Phone/Fax

Practice location:
  • Phone: 651-494-4446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL MORRISSEY BAHR
Title or Position: OWNER
Credential:
Phone: 651-494-4446