Healthcare Provider Details

I. General information

NPI: 1245155100
Provider Name (Legal Business Name): EMPOWERED RECOVERY SOLUTIONS 'LIFE AFTER' RECOVERY RESIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12714 FREMONT AVE
ZIMMERMAN MN
55398-9406
US

IV. Provider business mailing address

6314 CEDAR RD
OAK PARK MN
56357-8529
US

V. Phone/Fax

Practice location:
  • Phone: 763-732-2065
  • Fax:
Mailing address:
  • Phone: 763-732-2065
  • Fax: 763-732-2065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: SHANNON TABAKA
Title or Position: OWNER/PROGRAM DIRECTOR
Credential: SW
Phone: 763-732-2065