Provider Demographics
NPI:1649756040
Name:WAYSIDE HOUSE, INC.
Entity Type:Organization
Organization Name:WAYSIDE HOUSE, INC.
Other - Org Name:WAYSIDE RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORREST-PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MHR LADC
Authorized Official - Phone:651-242-5542
Mailing Address - Street 1:3705 PARK CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1349 JERSEY AVE S
Practice Address - Street 2:
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-542-9322
Practice Address - Fax:952-542-0031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYSIDE HOUSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1092849261QM0801X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)