Healthcare Provider Details

I. General information

NPI: 1902973712
Provider Name (Legal Business Name): AMHERST H. WILDER FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 LAFOND AVE
SAINT PAUL MN
55104-2108
US

IV. Provider business mailing address

919 LAFOND AVE
SAINT PAUL MN
55104-2108
US

V. Phone/Fax

Practice location:
  • Phone: 651-642-4094
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CRAIG BINGER
Title or Position: VICE PRESIDENT ADMINISTRATION
Credential:
Phone: 651-642-4000