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General NPI Number Information
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NPI Number | 1457022501
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Entity Type | Organization
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Legal Business Name | THERESAS HOME LLC
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Dates
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Enumeration Date | 09/27/2021
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Last Update Date | 09/27/2021
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Provider Practice Location Address
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Address Line | 224 2ND AVE S
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City | SOUTH SAINT PAUL
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State | MN
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Zip | 55075-2346
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Country | US
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Telephone | 763-291-4288
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Fax |
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Provider Business Mailing Address
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Address Line | 9985 AUSTIN ST NE
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City | CIRCLE PINES
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State | MN
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Zip | 55014-2412
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Country | US
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Telephone | 763-291-4288
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. VIVIAN NGONGANG OGUNYEMI
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Credential | DNP
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Telephone | 763-291-4288
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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