MEDICARE: LAKELAND RECOVERY, 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	3245S0500X	Children's Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1992262794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKELAND RECOVERY, LLC

Provider Business Mailing Address
First Line	:	3306 ROLLING HILLS DR
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55121-2345
Country	:	US
Telephone Number	:	612-280-1012
Fax Number	:

Provider Business Practice Location Address
First Line	:	3427 CENTRAL AVE NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-1221
Country	:	US
Telephone Number	:	612-788-9757
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL SYLTIE
Credential	:
Telephone Number	:	612-280-1012

Provider Enumeration Date	:	02/28/2019
Last Update Date	:	02/28/2019

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Directions to “LAKELAND RECOVERY, LLC ” Practice Location

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