Provider Demographics
NPI:1417492810
Name:NEW LIFE TREATMENT CENTER
Entity Type:Organization
Organization Name:NEW LIFE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-777-4321
Mailing Address - Street 1:130 DAKOTA ST S
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56186-1037
Mailing Address - Country:US
Mailing Address - Phone:507-777-4321
Mailing Address - Fax:507-777-4284
Practice Address - Street 1:130 DAKOTA ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:MN
Practice Address - Zip Code:56186
Practice Address - Country:US
Practice Address - Phone:507-777-4321
Practice Address - Fax:507-777-4284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty