Provider Demographics
NPI:1932278538
Name:MINNESOTA TEEN CHALLENGE, INC.
Entity Type:Organization
Organization Name:MINNESOTA TEEN CHALLENGE, INC.
Other - Org Name:MINNESOTA TEEN CHALLENGE
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAULIEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-257-5301
Mailing Address - Street 1:740 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404
Mailing Address - Country:US
Mailing Address - Phone:612-373-3366
Mailing Address - Fax:612-333-4111
Practice Address - Street 1:1717 2ND AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403
Practice Address - Country:US
Practice Address - Phone:612-373-3366
Practice Address - Fax:612-333-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10090493CDT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility