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General NPI Number Information
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NPI Number | 1508309162
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Entity Type | Organization
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Legal Business Name | UNIVERSAL SUPPORT AGENCY, LLC.
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Dates
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Enumeration Date | 11/29/2016
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Last Update Date | 11/29/2016
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Provider Practice Location Address
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Address Line | 4513 WINCHESTER LN
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City | BROOKLYN CENTER
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State | MN
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Zip | 55429-1725
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Country | US
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Telephone | 763-951-9049
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Fax |
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Provider Business Mailing Address
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Address Line | 4513 WINCHESTER LN
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City | BROOKLYN CENTER
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State | MN
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Zip | 55429-1725
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | RICHARD VUE
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Credential |
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Telephone | 763-951-9049
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 08738
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License Number State | MN
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