1235237199 NPI number — FIVE STAR RECOVERY CENTER

Table of content: (NPI 1235237199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235237199 NPI number — FIVE STAR RECOVERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR RECOVERY CENTER
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:
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:
1235237199
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 E 2ND ST
Provider Second Line Business Mailing Address:
SUITE 110B
Provider Business Mailing Address City Name:
CHASKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55318-1966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-448-6557
Provider Business Mailing Address Fax Number:
952-448-6047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 E 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 110B
Provider Business Practice Location Address City Name:
CHASKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55318-1966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-448-6557
Provider Business Practice Location Address Fax Number:
952-448-6047
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VANDERSCOFF
Authorized Official First Name:
JASON
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
952-448-6557

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 82387 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 724455000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8409617 . This is a "UBH / MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1031769 . This is a "PREF ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4C35FI . This is a "BLUE CROSS BLUE SHIELD MN" identifier . This identifiers is of the category "OTHER".




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