Provider Demographics
NPI:1265098602
Name:ADVANCE SUPPORT SERVICES
Entity type:Organization
Organization Name:ADVANCE SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BALLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARSAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-242-1893
Mailing Address - Street 1:3055 OLD HIGHWAY 8 STE 101A
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2500
Mailing Address - Country:US
Mailing Address - Phone:612-242-1893
Mailing Address - Fax:
Practice Address - Street 1:3055 OLD HIGHWAY 8 STE 101A
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-2500
Practice Address - Country:US
Practice Address - Phone:612-242-1893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN02OtherMENTAL HEALTH