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General NPI Number Information
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NPI Number | 1013311802
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Entity Type | Organization
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Legal Business Name | TWIN CITIES BEHAVIORAL HEALTH PC
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Dates
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Enumeration Date | 10/22/2014
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Last Update Date | 10/22/2014
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Provider Practice Location Address
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Address Line | 2 DIVISION ST E STE 103
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City | BUFFALO
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State | MN
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Zip | 55313-1774
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Country | US
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Telephone | 612-998-5669
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Fax |
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Provider Business Mailing Address
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Address Line | 8120 PENN AVE S STE 554
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City | BLOOMINGTON
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State | MN
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Zip | 55431-1333
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Country | US
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Telephone | 612-998-5669
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Fax | 952-831-3559
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Authorized Official
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Title or Position | OWNER
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Name | JOSEPH SHAGALOW
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Credential | LP
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Telephone | 612-998-5669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 1074289
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License Number State | MN
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