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General NPI Number Information
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NPI Number | 1922275148
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Entity Type | Organization
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Legal Business Name | TEMPORARY LIVING CENTER
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Dates
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Enumeration Date | 05/15/2008
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Last Update Date | 05/15/2008
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Provider Practice Location Address
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Address Line | 7170 BRYANT LAKE DR
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-3502
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Country | US
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Telephone | 952-942-6400
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Fax |
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Provider Business Mailing Address
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Address Line | 7170 BRYANT LAKE DR
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-3502
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Country | US
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Telephone | 952-942-6400
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. JACQUE LEE ROBINSON-RICHARD
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Credential |
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Telephone | 337-303-3536
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number | 1010423
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License Number State | MN
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