Provider Demographics
NPI:1528360591
Name:MINNESOTA TEEN CHALLENGE, INC
Entity Type:Organization
Organization Name:MINNESOTA TEEN CHALLENGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAULIEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-257-5301
Mailing Address - Street 1:2424 BUSINESS 371
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-8306
Mailing Address - Country:US
Mailing Address - Phone:218-833-8777
Mailing Address - Fax:218-833-8778
Practice Address - Street 1:2424 BUSINESS 371
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-8306
Practice Address - Country:US
Practice Address - Phone:218-833-8777
Practice Address - Fax:218-833-8778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1056824-1-CDT302F00000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No302F00000XManaged Care OrganizationsExclusive Provider Organization