Provider Demographics
NPI:1992171110
Name:TONKA LIFE CENTER
Entity type:Organization
Organization Name:TONKA LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA LP
Authorized Official - Phone:952-393-6280
Mailing Address - Street 1:3305 CASCO CIR
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-9718
Mailing Address - Country:US
Mailing Address - Phone:952-393-6280
Mailing Address - Fax:952-471-7211
Practice Address - Street 1:3305 CASCO CIR
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-9718
Practice Address - Country:US
Practice Address - Phone:952-393-6280
Practice Address - Fax:952-471-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1543103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty