Basic Information
| Provider Information | |||||||||
| NPI: | 1033233788 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEADOW CREEK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEADOW CREEK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN STREET | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267600 | ||||||||
| FaxNumber: | 6516313231 | ||||||||
| Practice Location | |||||||||
| Address1: | 17305 MEADOW CREEK LANE | ||||||||
| Address2: | |||||||||
| City: | PINE CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634444838 | ||||||||
| FaxNumber: | 7634446007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 09/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LINDEMAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENUE CYCLE MGMT | ||||||||
| AuthorizedOfficialTelephone: | 6123267566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 804733 | MN | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | 1033825 2 DS | MN | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | 804733 2 CDT | MN | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.