Provider Demographics
NPI:1083433650
Name:BEACON OF HOPE AUTISM CENTER LLC
Entity type:Organization
Organization Name:BEACON OF HOPE AUTISM CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TABITA
Authorized Official - Middle Name:A
Authorized Official - Last Name:OMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-363-0319
Mailing Address - Street 1:85 LIVINGSTON AVE APT 313
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-5705
Mailing Address - Country:US
Mailing Address - Phone:651-363-0319
Mailing Address - Fax:
Practice Address - Street 1:85 LIVINGSTON AVE APT 313
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-5705
Practice Address - Country:US
Practice Address - Phone:651-363-0319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health