Provider Demographics
NPI:1407449846
Name:ALLY SUPPORTIVE SERVICES, LLC
Entity Type:Organization
Organization Name:ALLY SUPPORTIVE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TONNANCOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-302-4471
Mailing Address - Street 1:PO BOX 544
Mailing Address - Street 2:
Mailing Address - City:SOUTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-0544
Mailing Address - Country:US
Mailing Address - Phone:651-302-4471
Mailing Address - Fax:651-760-4334
Practice Address - Street 1:245 MARIE AVE E STE 107
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-4280
Practice Address - Country:US
Practice Address - Phone:651-302-4471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA720082300OtherSTATE OF MINNESOTA