Organization
INTERLACHEN LODGE OPERATED BY INTERLODGE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN TREPP (EXECUTIVE DIRECTOR)
(612) 871-3320
Entity
Organization
Contact information
Practice address
5141 WILLIAM AVE, EDINA, MN 55436-2126
(952) 767-0360
(952) 922-8892
Mailing address
2419 NICOLLET AVE, MINNEAPOLIS, MN 55404-3450
(612) 871-3320
(612) 871-0432
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
1044976
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1044976
DEPT. OF HUMAN SERVICES -
MN
Enumeration date
07/18/2007
Last updated
07/18/2007
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