Basic Information
| Provider Information | |||||||||
| NPI: | 1497961759 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO TREATMENT OF MINNESOTA LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAKOTA TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 MAITLAND CENTER PARKWAY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073517080 | ||||||||
| FaxNumber: | 4073516930 | ||||||||
| Practice Location | |||||||||
| Address1: | 11939 WEST RIVER HILLS DR | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553371354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528904480 | ||||||||
| FaxNumber: | 9528904943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4073517080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO TREATMENT OF MINNESOTA LP | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 831007-2-CDT | MN | N | Agencies | Community/Behavioral Health | 3336C0002X | 261484-7 | MN | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.