Provider Demographics
NPI:1649636689
Name:MINNESOTA TEEN CHALLNGE, INC.
Entity type:Organization
Organization Name:MINNESOTA TEEN CHALLNGE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREATMENT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:218-833-8758
Mailing Address - Street 1:1619 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1507
Mailing Address - Country:US
Mailing Address - Phone:218-833-8777
Mailing Address - Fax:218-828-6932
Practice Address - Street 1:313 LAUREL ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3522
Practice Address - Country:US
Practice Address - Phone:218-833-8758
Practice Address - Fax:218-828-6932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1078601-1-CDT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility