Healthcare Provider Details

I. General information

NPI: 1871641373
Provider Name (Legal Business Name): WINGSPAN LIFE RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PLATO BLVD E
SAINT PAUL MN
55107-1809
US

IV. Provider business mailing address

30 PLATO BLVD E
SAINT PAUL MN
55107-1809
US

V. Phone/Fax

Practice location:
  • Phone: 651-242-5840
  • Fax:
Mailing address:
  • Phone: 651-242-5840
  • Fax: 651-646-2347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberHFID 01287
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberHFID 01198
License Number StateMN

VIII. Authorized Official

Name: MS. THERESE G DAVIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 651-242-5840