Provider Demographics
NPI:1578989984
Name:AUGSBURG FAIRVIEW ACADEMY
Entity Type:Organization
Organization Name:AUGSBURG FAIRVIEW ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-294-1032
Mailing Address - Street 1:2504 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4432
Mailing Address - Country:US
Mailing Address - Phone:612-333-1614
Mailing Address - Fax:
Practice Address - Street 1:2504 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4432
Practice Address - Country:US
Practice Address - Phone:612-333-1614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty