Provider Demographics
NPI:1194241166
Name:FIVE STARS RECOVERY CENTER
Entity type:Organization
Organization Name:FIVE STARS RECOVERY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERSCOFF
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:952-448-6557
Mailing Address - Street 1:1045 STOUGHTON AVE.
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1045 STOUGHTON AVE.
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318
Practice Address - Country:US
Practice Address - Phone:952-448-6557
Practice Address - Fax:952-448-6047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
24D2130068291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN473724996Medicaid