Provider Demographics
NPI:1992521116
Name:SOUTH LAKE AUTISM CENTER L. L. C.
Entity type:Organization
Organization Name:SOUTH LAKE AUTISM CENTER L. L. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIKHDOON
Authorized Official - Middle Name:JAMA
Authorized Official - Last Name:WARSAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-992-1536
Mailing Address - Street 1:2147 UNIVERSITY AVE W STE 108
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1326
Mailing Address - Country:US
Mailing Address - Phone:617-992-1536
Mailing Address - Fax:
Practice Address - Street 1:2147 UNIVERSITY AVE W STE 109
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1326
Practice Address - Country:US
Practice Address - Phone:617-992-1536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-03
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center