Provider Demographics
NPI:1134630734
Name:C10202017363071
Entity type:Organization
Organization Name:C10202017363071
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:ZEIDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:763-245-8278
Mailing Address - Street 1:C/O MERIDIAN BEHAVIORAL HEALTH #190
Mailing Address - Street 2:550 MAIN STREET
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:612-454-2046
Mailing Address - Fax:
Practice Address - Street 1:109 N SHORE DR
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:MN
Practice Address - Zip Code:55390
Practice Address - Country:US
Practice Address - Phone:763-658-5800
Practice Address - Fax:763-658-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty