Provider Demographics
NPI:1235237199
Name:FIVE STAR RECOVERY CENTER
Entity Type:Organization
Organization Name:FIVE STAR RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:VANDERSCOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-448-6557
Mailing Address - Street 1:102 E 2ND ST
Mailing Address - Street 2:SUITE 110B
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1966
Mailing Address - Country:US
Mailing Address - Phone:952-448-6557
Mailing Address - Fax:952-448-6047
Practice Address - Street 1:102 E 2ND ST
Practice Address - Street 2:SUITE 110B
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1966
Practice Address - Country:US
Practice Address - Phone:952-448-6557
Practice Address - Fax:952-448-6047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN82387OtherHEALTH PARTNERS
MN724455000Medicaid
MN8409617OtherUBH / MEDICA
MN1031769OtherPREF ONE
4C35FIOtherBLUE CROSS BLUE SHIELD MN