Provider Demographics
NPI:1104374073
Name:LAKES OPIOID TREATMENT PROGRAM, INC
Entity Type:Organization
Organization Name:LAKES OPIOID TREATMENT PROGRAM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:LOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-877-2465
Mailing Address - Street 1:15477 SODIUM ST NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-5415
Mailing Address - Country:US
Mailing Address - Phone:763-412-9441
Mailing Address - Fax:
Practice Address - Street 1:8381 LAKE LAND TRL NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MN
Practice Address - Zip Code:56484-2109
Practice Address - Country:US
Practice Address - Phone:763-412-9441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder