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General NPI Number Information
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NPI Number | 1003261983
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Entity Type | Organization
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Legal Business Name | LAO ADVANCEMENT ORGANIZATION OF AMERICA (LAOA)
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Dates
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Enumeration Date | 04/28/2016
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Last Update Date | 04/28/2016
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Provider Practice Location Address
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Address Line | 2648 W BROADWAY AVE
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City | MINNEAPOLIS
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State | MN
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Zip | 55411-1004
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Country | US
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Telephone | 612-302-9154
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Fax | 612-522-2431
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Provider Business Mailing Address
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Address Line | 2648 W BROADWAY AVE
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City | MINNEAPOLIS
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State | MN
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Zip | 55411-1004
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Country | US
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Telephone | 612-302-9154
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Fax | 612-522-2431
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. KHAMCHANH NMN PHANTHAVONG
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Credential | PH.D.
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Telephone | 612-302-9154
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | 1075697
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License Number State | MN
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