Provider Demographics
NPI:1659764587
Name:NORTHSTAR REGIONAL
Entity Type:Organization
Organization Name:NORTHSTAR REGIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERSCOFF
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:612-964-4312
Mailing Address - Street 1:1045 STOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2149
Mailing Address - Country:US
Mailing Address - Phone:952-448-6557
Mailing Address - Fax:952-448-6047
Practice Address - Street 1:1045 STOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2149
Practice Address - Country:US
Practice Address - Phone:952-974-3999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health