Organization
WINGSPAN LIFE RESOURCES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. THERESE G DAVIS (EXECUTIVE DIRECTOR)
(651) 242-5840
Entity
Organization
Contact information
Practice address
30 PLATO BLVD E, SAINT PAUL, MN 55107-1809
(651) 242-5840
Mailing address
30 PLATO BLVD E, SAINT PAUL, MN 55107-1809
(651) 242-5840
(651) 646-2347
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
HFID 01198
MN
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
HFID 01287
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014245000
ICFMR - 91ST STR
MN
01
—
047148000
ICFMR - MARSHALL
MN
Enumeration date
01/08/2007
Last updated
06/24/2019
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