Interlachen Lodge Operated by Interlodge

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

License

1044976 Issued in MN

Legal business name

INTERLACHEN LODGE OPERATED BY INTERLODGE

Practice address

5141 William Ave
Edina, MN 55436-2126

Phone

(952) 767-0360

Fax

(952) 922-8892

NPI assigned

Jul 18, 2007

Organization subpart

No

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

Authorized official

Name

John Trepp

Title

Executive Director

Phone

(612) 871-3320

Specialties & licenses 1

Addresses

Other identifiers 1

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

{
    "created_epoch": "1184716800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1184716800000",
    "number": "1427258599",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2419 NICOLLET AVE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554043450",
            "telephone_number": "612-871-3320",
            "fax_number": "612-871-0432"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5141 WILLIAM AVE",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554362126",
            "telephone_number": "952-767-0360",
            "fax_number": "952-922-8892"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTERLACHEN LODGE OPERATED BY INTERLODGE",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-18",
        "last_updated": "2007-07-18",
        "status": "A",
        "authorized_official_last_name": "TREPP",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "612-871-3320"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "MN",
            "license": "1044976",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPT. OF HUMAN SERVICES -",
            "identifier": "1044976",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Integrated Provider Group of Minnesota
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• Integro Clinic PLLC
• Interlachen Dental Associates
• Interlachen Dental Associates
• Intermed Consultants Dialysis, PLLC
• Intermed Consultants,LTD.
• Intrepid of Golden Valley Inc
• Brian Ip, M.D.
• Darci Isaksen, ACSM HF/I

• Community/Behavioral Health Agency in Edina, MN
• Providers in Edina, MN by specialty
• Community/Behavioral Health Agency in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2007; 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.