Basic Information
| Provider Information | |||||||||
| NPI: | 1629120563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COURAGE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOME AND COMMUNITY BASED REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3915 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125880811 | ||||||||
| FaxNumber: | 7635200237 | ||||||||
| Practice Location | |||||||||
| Address1: | 3915 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125880811 | ||||||||
| FaxNumber: | 7635200237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 04/25/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7635200283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | 8356799 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 6899HCU | 01 | MN | BCBS OF MN | OTHER | 1041648 | 01 | MN | PREFERRED ONE | OTHER |