1124234653 NPI number — METRO TREATMENT OF MINNESOTA LP

Table of content: (NPI 1124234653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124234653 NPI number — METRO TREATMENT OF MINNESOTA LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO TREATMENT OF MINNESOTA LP
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:
ST. CLOUD METRO TREATMENT CENTER
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:
1124234653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 MAITLAND CENTER PARKWAY
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-4174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-351-7080
Provider Business Mailing Address Fax Number:
407-351-6930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
524 25TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-3255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-202-1909
Provider Business Practice Location Address Fax Number:
320-202-1910
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
407-351-7080

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  1035458-1-CDT , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0002X , with the licence number: 262696-1 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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