Provider Demographics
NPI:1295219657
Name:AWAKEN RECOVERY CENTER L.L.C
Entity Type:Organization
Organization Name:AWAKEN RECOVERY CENTER L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-331-2162
Mailing Address - Street 1:400 SUITE D 393 NORTH DUNLAP
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:763-331-2162
Mailing Address - Fax:651-340-6888
Practice Address - Street 1:400 SUITE D 393 NORTH DUNLAP
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:763-331-2162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AWAKEN RECOVERY CENTER L.L.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty