1871826982 NPI number — ARC MINNETONKA LLC

Table of content: (NPI 1871826982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871826982 NPI number — ARC MINNETONKA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARC MINNETONKA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FREEDOM POINTE MINNETONKA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871826982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 CARLSON PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNETONKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55305-5304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-473-3330
Provider Business Mailing Address Fax Number:
952-473-7555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 CARLSON PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-5304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-473-3330
Provider Business Practice Location Address Fax Number:
952-473-7555
Provider Enumeration Date:
09/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RIJOS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CO-PRESIDENT
Authorized Official Telephone Number:
312-977-3700

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A590168500 . This is a "MEDICAID WAIVER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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