Basic Information
Provider Information | |||||||||
NPI: | 1386229748 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NYSTROM RESIDENTIAL TREATMENT, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 SILVER LAKE RD NW | ||||||||
Address2: |   | ||||||||
City: | NEW BRIGHTON | ||||||||
State: | MN | ||||||||
PostalCode: | 551121786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6516289566 | ||||||||
FaxNumber: | 6516280411 | ||||||||
Practice Location | |||||||||
Address1: | 19580 STATION ST | ||||||||
Address2: |   | ||||||||
City: | BIG LAKE | ||||||||
State: | MN | ||||||||
PostalCode: | 553099411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7633092021 | ||||||||
FaxNumber: | 7633092022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2021 | ||||||||
LastUpdateDate: | 03/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ARNOLD | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6516289566 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   |   | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
No ID Information.