1245318377 NPI number — THRIVE BEHAVIORAL NETWORK IV, LLC

Table of content: (NPI 1245318377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245318377 NPI number — THRIVE BEHAVIORAL NETWORK IV, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THRIVE BEHAVIORAL NETWORK IV, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEW VISIONS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245318377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 DOCTORS PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-255-9530
Provider Business Mailing Address Fax Number:
320-251-2996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 9TH AVE WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56308-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-763-3912
Provider Business Practice Location Address Fax Number:
320-763-6629
Provider Enumeration Date:
11/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRADLEY
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
320-763-3912

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  1036409 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 674407901 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".