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General NPI Number Information
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NPI Number | 1235237199
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Entity Type | Organization
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Legal Business Name | FIVE STAR RECOVERY CENTER
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 11/25/2008
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Provider Practice Location Address
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Address Line | 102 E 2ND ST SUITE 110B
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City | CHASKA
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State | MN
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Zip | 55318-1966
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Country | US
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Telephone | 952-448-6557
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Fax | 952-448-6047
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Provider Business Mailing Address
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Address Line | 102 E 2ND ST SUITE 110B
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City | CHASKA
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State | MN
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Zip | 55318-1966
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Country | US
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Telephone | 952-448-6557
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Fax | 952-448-6047
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | MR. JASON DAVID VANDERSCOFF
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Credential |
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Telephone | 952-448-6557
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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