Provider Demographics
NPI:1427258599
Name:INTERLACHEN LODGE OPERATED BY INTERLODGE
Entity type:Organization
Organization Name:INTERLACHEN LODGE OPERATED BY INTERLODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TREPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-871-3320
Mailing Address - Street 1:2419 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3450
Mailing Address - Country:US
Mailing Address - Phone:612-871-3320
Mailing Address - Fax:612-871-0432
Practice Address - Street 1:5141 WILLIAM AVE
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2126
Practice Address - Country:US
Practice Address - Phone:952-767-0360
Practice Address - Fax:952-922-8892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1044976251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1044976OtherDEPT. OF HUMAN SERVICES -