1487088290 NPI number — LATITUDES TREATMENT CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487088290 NPI number — LATITUDES TREATMENT CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LATITUDES TREATMENT CENTER 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:
Provider Other Organization Name Type Code:
6
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:
1487088290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1609 JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55117-3917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-326-7611
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 MAIN ST STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRIGHTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55112-3274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-326-7600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ZEIDNER
Authorized Official First Name:
LEWIS
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
763-245-8278

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  1066083 , 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)





Copyright © 2007-2025 www.npivalidator.com