Provider Demographics
NPI:1922275148
Name:TEMPORARY LIVING CENTER
Entity Type:Organization
Organization Name:TEMPORARY LIVING CENTER
Other - Org Name:TLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROBINSON-RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-303-3536
Mailing Address - Street 1:7170 BRYANT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3502
Mailing Address - Country:US
Mailing Address - Phone:952-942-6400
Mailing Address - Fax:
Practice Address - Street 1:7170 BRYANT LAKE DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3502
Practice Address - Country:US
Practice Address - Phone:952-942-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10104233245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2719550000OtherMN ITS