Provider Demographics
NPI:1902012107
Name:METRO TREATMENT OF MINNESOTA, LP
Entity Type:Organization
Organization Name:METRO TREATMENT OF MINNESOTA, LP
Other - Org Name:LAKE SUPERIOR TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CHUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-351-7080
Mailing Address - Street 1:14050 TOWN LOOP BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6190
Mailing Address - Country:US
Mailing Address - Phone:407-351-7080
Mailing Address - Fax:407-351-6930
Practice Address - Street 1:14 E CENTRAL ENTRANCE
Practice Address - Street 2:SUITE B
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5508
Practice Address - Country:US
Practice Address - Phone:218-786-0223
Practice Address - Fax:218-786-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1008733-1-CDT251S00000X
MN261964-83336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No3336C0002XSuppliersPharmacyClinic Pharmacy