| NPI | 1780234955 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CLARENCE LEONARD BONANDER Owner 612-600-8431 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 251S00000X |
| 305S00000X Point of Service | |
| Enumeration Date | 2019-09-18 |
| Last Update Date | 2019-09-18 |