MEDICARE: REENTRY HOUSE, 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	320800000X	Mental Illness Community Based Residential Treatment Facility	802063-2-RMI	MN

General Provider Information

NPI Number	:	1679656771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REENTRY HOUSE, INC.

Provider Business Mailing Address
First Line	:	5812 LYNDALE AVENUE SOUTH
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419
Country	:	US
Telephone Number	:	612-869-2411
Fax Number	:	612-869-0313

Provider Business Practice Location Address
First Line	:	1313 5TH ST SE
Second Line	:	SUITE #314
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-4504
Country	:	US
Telephone Number	:	612-435-7200
Fax Number	:	612-435-7201

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. TERRY M. SCHNEIDER
Credential	:	LICENSED PSYCHOLOGIS
Telephone Number	:	612-869-2411

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	08/22/2020

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