Provider Demographics
NPI:1538312939
Name:AMHERST H. WILDER FOUNDATION
Entity Type:Organization
Organization Name:AMHERST H. WILDER FOUNDATION
Other - Org Name:BUSH EVENING TREATMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-280-2000
Mailing Address - Street 1:451 LEXINGTON PKWY N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4636
Mailing Address - Country:US
Mailing Address - Phone:651-280-2000
Mailing Address - Fax:651-280-3995
Practice Address - Street 1:451 LEXINGTON PKWY N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4636
Practice Address - Country:US
Practice Address - Phone:651-280-2000
Practice Address - Fax:651-280-3995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN555055600OtherMEDICAL ASSISTANCE