Provider Demographics
NPI:1932413887
Name:THE WAYSIDE HOUSE, INC.
Entity Type:Organization
Organization Name:THE WAYSIDE HOUSE, INC.
Other - Org Name:INCARNATION FAMILY CONNECTIONS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CPRP
Authorized Official - Phone:952-405-7636
Mailing Address - Street 1:3705 PARK CENTER BLVD.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-926-5626
Mailing Address - Fax:952-926-9713
Practice Address - Street 1:2120 CLINTON AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-871-0099
Practice Address - Fax:612-871-0929
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE WAYSIDE HOUSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1055132-1-CDT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility