Basic Information
| Provider Information | |||||||||
| NPI: | 1104950591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVALON PROGRAMS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVALON - PROSPECT PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN ST | ||||||||
| Address2: | STE 230 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267600 | ||||||||
| FaxNumber: | 6516313231 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 UNIVERSITY AVE SE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126382282 | ||||||||
| FaxNumber: | 6123267642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 12/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | LINDEMAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR - REVENUE CYCLE MGMT | ||||||||
| AuthorizedOfficialTelephone: | 6123267566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 1016848-4-CDT | MN | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101YA0400X | 1016848 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.