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General NPI Number Information
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NPI Number | 1821584657
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Entity Type | Organization
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Legal Business Name | AMAZING GRACE RECOVERY SERVICES, LLC
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Dates
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Enumeration Date | 07/04/2018
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Last Update Date | 07/04/2018
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Provider Practice Location Address
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Address Line | 23671 SAINT FRANCIS BLVD NW
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City | SAINT FRANCIS
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State | MN
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Zip | 55070-9802
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Country | US
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Telephone | 651-343-3670
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Fax |
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Provider Business Mailing Address
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Address Line | 35619 HELIUM ST NW
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City | PRINCETON
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State | MN
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Zip | 55371-4791
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Country | US
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Telephone | 651-343-3670
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MICHAEL LEADENS
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Credential | MA, LADC
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Telephone | 651-343-3670
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 1093306
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1093306
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License Number State | MN
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