Provider Demographics
NPI:1336473560
Name:OPTIONS RESIDENTIAL, INC
Entity Type:Organization
Organization Name:OPTIONS RESIDENTIAL, INC
Other - Org Name:DUPONT HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SAMMON
Authorized Official - Suffix:
Authorized Official - Credentials:LADC, LMFT
Authorized Official - Phone:612-226-7120
Mailing Address - Street 1:2105 W BURNSVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4237
Mailing Address - Country:US
Mailing Address - Phone:952-564-3030
Mailing Address - Fax:952-564-3038
Practice Address - Street 1:10101 DUPONT AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3139
Practice Address - Country:US
Practice Address - Phone:952-564-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTIONS RESIDENTIAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1052266-1-AFC253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA630173808Medicaid
MN138003OtherUCARE