Provider Demographics
NPI:1093143042
Name:BURNSVILLE CENTER FOR ADD AND ADDICTIONS, L.L.C.
Entity Type:Organization
Organization Name:BURNSVILLE CENTER FOR ADD AND ADDICTIONS, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:SCORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-898-1870
Mailing Address - Street 1:14724 INNSBROOK LN
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6455
Mailing Address - Country:US
Mailing Address - Phone:952-898-1870
Mailing Address - Fax:
Practice Address - Street 1:1601 SOUTHCROSS DR W
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-7013
Practice Address - Country:US
Practice Address - Phone:952-224-8990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2095261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350003589Medicare PIN
MNT84944Medicare UPIN