Organization
MICAH HOUSE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANTHONY SCOTT HOLMQUIST-BURKS LADC (CLINICAL SUPERVISOR)
(612) 827-0484
Entity
Organization
Contact information
Practice address
3047 5TH AVE S, MINNEAPOLIS, MN 55408-2415
(651) 827-0484
(612) 827-0485
Mailing address
3047 5TH AVE S, MINNEAPOLIS, MN 55408-2415
(651) 827-0484
(612) 827-0485
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
303472
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
303472
—
MN
Enumeration date
07/29/2015
Last updated
07/29/2015
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