Basic Information
| Provider Information | |||||||||
| NPI: | 1487088290 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LATITUDES TREATMENT CENTER LLC | ||||||||
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| OtherOrganizationName: | LATITUDES TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1609 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551173917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 MAIN ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551123274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2013 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6123267555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 1066083 | MN | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.