Healthcare Provider Details

I. General information

NPI: 1124111729
Provider Name (Legal Business Name): CENTER FOR VICTIMS OF TORTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 DAYTON AVE
SAINT PAUL MN
55104-6631
US

IV. Provider business mailing address

649 DAYTON AVE
SAINT PAUL MN
55104-6631
US

V. Phone/Fax

Practice location:
  • Phone: 612-436-4840
  • Fax:
Mailing address:
  • Phone: 612-436-4840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KA THAO
Title or Position: MEDICAL BILLING COORDINATOR
Credential:
Phone: 612-436-4860