Organization
TAMERNIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NICHOLAS JERYL GOEDEL (CEO)
(763) 607-1120
Entity
Organization
Contact information
Practice address
270 W MILKIWAY AVE, LAKE LILLIAN, MN 56253
(763) 607-1120
Mailing address
270 W MILKIWAY AVE, LAKE LILLIAN, MN 56253
Taxonomy
Speciality
Code
Description
License number
State
320700000X
Physical Disabilities Residential Treatment Facility
—
—
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1110595
245D LICENSE
MN
01
—
1112662
ADULT FOSTER CARE LICENSE
MN
Enumeration date
06/08/2022
Last updated
08/19/2022
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