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General NPI Number Information
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NPI Number | 1336432087
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Entity Type | Organization
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Legal Business Name | SOUTH EAST HOMES INC
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Dates
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Enumeration Date | 05/26/2011
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Last Update Date | 08/17/2012
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Provider Practice Location Address
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Address Line | 2732 BLOOMINGTON AVE
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City | MINNEAPOLIS
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State | MN
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Zip | 55407-1146
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Country | US
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Telephone | 612-702-7231
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Fax |
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Provider Business Mailing Address
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Address Line | 2542 17TH AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55404-4001
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Country | US
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Telephone | 612-702-7231
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Fax |
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Authorized Official
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Title or Position | JOHN PRIN
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Name | MS. ABAH ABDUL MOHAMED
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Credential | LADC
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Telephone | 612-702-7231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 1062832-1-CDT
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License Number State | MN
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