MEDICARE: TONKA LIFE CENTER, LTD

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1154988350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TONKA LIFE CENTER, LTD

Provider Business Mailing Address
First Line	:	400 10TH ST E
Second Line	:
City	:	WACONIA
State	:	MN
Zip	:	55387-4552
Country	:	US
Telephone Number	:	888-209-0305
Fax Number	:	952-442-3620

Provider Business Practice Location Address
First Line	:	1605 W WAYZATA BLVD
Second Line	:
City	:	LONG LAKE
State	:	MN
Zip	:	55356-9300
Country	:	US
Telephone Number	:	888-209-0305
Fax Number	:	952-442-3620

Authorized Official
Title or Position	:	OWNER
Name	:	BRIAN V NELSON
Credential	:	LP, LSP
Telephone Number	:	952-393-6280

Provider Enumeration Date	:	05/22/2019
Last Update Date	:	05/22/2019

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