# SAGE PRAIRIE LABORATORY

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** MEDICAL ADDICTION TREATMENT CLINIC
- **Other names:** Sage Prairie laboratory
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1164089447
- **Legal business name:** MEDICAL ADDICTION TREATMENT CLINIC
- **Authorized official:** GRANT ARNOLD PYLKAS MMA (EXECUTIVE DIRECTOR)
- **Authorized official phone:** (651) 238-5558

## Contact information

- **Practice address:** 1440 DUCKWOOD DR, EAGAN, MN 55122-1451
- **Practice address phone:** (651) 238-5558
- **Practice address fax:** (612) 437-4992
- **Mailing address:** 1440 DUCKWOOD DR STE 100, EAGAN, MN 55122-1451
- **Mailing address phone:** (651) 238-5558
- **Mailing address fax:** (612) 437-4992

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 246Z00000X | Other Specialist/Technologist | — | NULL | Yes |
| 246Z00000X | Other Specialist/Technologist | — | — | Yes |

## Other

- **Enumeration date:** 05/22/2019
- **Last updated:** 05/22/2019