Provider Demographics
NPI:1407356710
Name:REFRACTIONS LLC
Entity Type:Organization
Organization Name:REFRACTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:CORENE
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-252-6017
Mailing Address - Street 1:22575 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTA
Mailing Address - State:MN
Mailing Address - Zip Code:56301-8729
Mailing Address - Country:US
Mailing Address - Phone:320-223-1161
Mailing Address - Fax:
Practice Address - Street 1:22575 43RD AVE
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTA
Practice Address - State:MN
Practice Address - Zip Code:56301-8729
Practice Address - Country:US
Practice Address - Phone:320-223-1161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-14
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00597101YP2500X
320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty