1598848939 NPI number — SENIOR RECOVERY PROGRAM

Table of content: (NPI 1598848939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598848939 NPI number — SENIOR RECOVERY PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENIOR RECOVERY PROGRAM
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:
SENIOR CHEMICAL DEPENDENCY COUNSELING AND ASSISTANCE ASSOCIATION
Provider Other Organization Name Type Code:
4
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:
1598848939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2375 ARIEL AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLEWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-773-0473
Provider Business Mailing Address Fax Number:
651-773-9298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2375 ARIEL AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-773-0473
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLAWSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
651-773-0473

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  808754-3-CDT , 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: 808754 . This is a "RULE 31 CLINIC DEPT OF HUMAN SERVICES" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 446517200 . This is a "CONSOLIDATED FUND" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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