1144227430 NPI number — LIVING FREE RECOVERY SERVICES, LLC

Table of content: (NPI 1144227430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144227430 NPI number — LIVING FREE RECOVERY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING FREE RECOVERY SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIVING WORD CHRISTIAN CENTER DBA LIVING FREE RECOVERY SERVICES
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144227430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9201 75TH AVENUE NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-315-7000
Provider Business Mailing Address Fax Number:
763-315-7177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9201 75TH AVENUE NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-315-7000
Provider Business Practice Location Address Fax Number:
763-315-7177
Provider Enumeration Date:
07/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAASE
Authorized Official First Name:
TREENA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
763-315-7174

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  830992-2-CDT , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 251922400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0C20LI . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8442759 . This is a "UBH - ADULT" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8446051 . This is a "UBH- ASSESSMENT ONLY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8442760 . This is a "UBH - ADOLESCENT" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8442761 . This is a "UBH - RELAPSE" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".




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