National Provider Identifier Database

C10202017363071
Substance Abuse Disorder Rehabilitation Facility

A facility or distinct part of a facility that provides a 24 hr therapeutically planned living and rehabilitative intervention environment for the treatment of individuals with disorders in the abuse of drugs, alcohol, and other substances.


Contact Information

C10202017363071
109 N SHORE DR
WAVERLY, MN55390
Phone: 763-658-5800
Fax: 763-658-4128
Website:
Specialty Taxonomy Code
* Substance Abuse Disorder Rehabilitation Facility 324500000X

* Indicates primary specialty

NPI Profile & details for C10202017363071

NPI Number 1134630734
Legal business name
LBN
C10202017363071
Authorized official LEWIS ZEIDNER - (CEO)
Entity Organization
Organization subpart No
Enumeration date 10/23/2017
Last updated 02/21/2025 - More than a year ago
Sole proprietor1 Not specified
Identifiers n/a

1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.

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