Provider Demographics
NPI:1326822529
Name:DAMASCUS WAY
Entity Type:Organization
Organization Name:DAMASCUS WAY
Other - Org Name:DAMASCUS WAY REENTRY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIERRE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:LGSW
Authorized Official - Phone:612-746-5631
Mailing Address - Street 1:5830 OLSON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5016
Mailing Address - Country:US
Mailing Address - Phone:763-545-6558
Mailing Address - Fax:
Practice Address - Street 1:1515 E 66TH ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2648
Practice Address - Country:US
Practice Address - Phone:763-545-6558
Practice Address - Fax:763-275-9951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-21
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty