=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942863378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUTAPONA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2019
-----------------------------------------------------
Last Update Date | 04/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1935 COUNTY ROAD B2 W STE 270
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-2785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-222-6028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 214
-----------------------------------------------------
City | NEW RICHMOND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54017-0214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-222-6028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CARL GAEDE
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 715-222-6028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------