Nystrom Residential Treatment, LLC

Primary specialty

Substance Abuse Rehabilitation FacilityTaxonomy code 324500000X

Legal business name

NYSTROM RESIDENTIAL TREATMENT, LLC

Practice address

19580 Station St
Big Lake, MN 55309-9411

Phone

(763) 309-2021

Fax

(763) 309-2022

NPI assigned

Mar 16, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ann Eiden

Title

VP of Corporate Services

Phone

(651) 379-1750

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1615852800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1743984000000",
    "number": "1386229748",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 SILVER LAKE RD NW",
            "city": "NEW BRIGHTON",
            "state": "MN",
            "postal_code": "551121786",
            "telephone_number": "651-628-9566",
            "fax_number": "651-628-0411"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19580 STATION ST",
            "city": "BIG LAKE",
            "state": "MN",
            "postal_code": "553099411",
            "telephone_number": "763-309-2021",
            "fax_number": "763-309-2022"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NYSTROM RESIDENTIAL TREATMENT, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-03-16",
        "last_updated": "2025-04-07",
        "certification_date": "2025-04-07",
        "status": "A",
        "authorized_official_last_name": "EIDEN",
        "authorized_official_first_name": "ANN",
        "authorized_official_title_or_position": "VP OF CORPORATE SERVICES",
        "authorized_official_telephone_number": "651-379-1750"
    },
    "taxonomies": [
        {
            "code": "324500000X",
            "taxonomy_group": "",
            "desc": "Substance Abuse Rehabilitation Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Deborah M Myhre
• Diane Lisa Neal, M.S. , LPCC
• Sylvia Kooyman Nelson, MT
• Sean Nielsen
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• Dylan Michael O'Borsky, DDS
• John Olafson, NP
• David Pachuta, D.D.S.
• Sherry Lynn Parker, LADC
• PDG, PA

• Substance Abuse Rehabilitation Facility in Big Lake, MN
• Providers in Big Lake, MN by specialty
• Substance Abuse Rehabilitation Facility in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 7, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.