Provider Demographics
NPI:1831254408
Name:THEODORE I
Entity type:Organization
Organization Name:THEODORE I
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-501-2378
Mailing Address - Street 1:1865 OLD HUDSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4308
Mailing Address - Country:US
Mailing Address - Phone:651-501-2378
Mailing Address - Fax:651-738-1737
Practice Address - Street 1:1314 LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-2409
Practice Address - Country:US
Practice Address - Phone:651-501-2378
Practice Address - Fax:651-738-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN802493-1-RMI320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness