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General NPI Number Information
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NPI Number | 1578075750
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Entity Type | Organization
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Legal Business Name | MIDWEST RESIDENTIAL INC
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Dates
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Enumeration Date | 10/28/2017
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Last Update Date | 03/18/2024
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Provider Practice Location Address
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Address Line | 10917 HUMBOLDT AVE S
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City | BLOOMINGTON
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State | MN
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Zip | 55431-4221
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Country | US
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Telephone | 651-315-2649
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Fax |
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Provider Business Mailing Address
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Address Line | 7400 CEDAR AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55423-4647
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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
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Name | FAIZA HASSAN
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Credential |
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Telephone | 651-315-2649
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 381821
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License Number State | MN
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