| NPI | 1124471107 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER M LAKE Owner 651-330-6205 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X Community/Behavioral Health (Licence: MN 2425) |
| Enumeration Date | 2016-07-14 |
| Last Update Date | 2021-12-14 |