Provider Demographics
NPI:1871641373
Name:WINGSPAN LIFE RESOURCES
Entity Type:Organization
Organization Name:WINGSPAN LIFE RESOURCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-242-5840
Mailing Address - Street 1:30 PLATO BLVD E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1809
Mailing Address - Country:US
Mailing Address - Phone:651-242-5840
Mailing Address - Fax:651-646-2347
Practice Address - Street 1:30 PLATO BLVD E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1809
Practice Address - Country:US
Practice Address - Phone:651-242-5840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNHFID 01198320600000X
MNHFID 01287320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN014245000OtherICFMR - 91ST STR
MN047148000OtherICFMR - MARSHALL