MEDICARE: NORTHWAY ACADEMY, INC.

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1174891584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWAY ACADEMY, INC.

Provider Business Mailing Address
First Line	:	6600 FRANCE AVE S STE 350
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-1810
Country	:	US
Telephone Number	:	952-563-2207
Fax Number	:	952-922-6885

Provider Business Practice Location Address
First Line	:	6600 FRANCE AVE S STE 350
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-1810
Country	:	US
Telephone Number	:	952-563-2207
Fax Number	:	952-922-6885

Authorized Official
Title or Position	:	CEO
Name	:	PHILIP ROBERTS KAUFMAN
Credential	:
Telephone Number	:	800-388-5150

Provider Enumeration Date	:	12/13/2011
Last Update Date	:	01/23/2024

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