MEDICARE: GOLDENVILLE AUTISM CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1134914690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDENVILLE AUTISM CENTER LLC

Provider Business Mailing Address
First Line	:	1405 SILVER LAKE RD NW STE 16
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9309
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 SILVER LAKE RD NW STE 16
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9309
Country	:	US
Telephone Number	:	612-839-7087
Fax Number	:

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	BAHJU SALAT
Credential	:
Telephone Number	:	612-839-7087

Provider Enumeration Date	:	04/14/2025
Last Update Date	:	04/14/2025

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