1407919210 NPI number — ACHIEVE THERAPY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407919210 NPI number — ACHIEVE THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACHIEVE THERAPY 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:
ACHIEVE THERAPY OF PARK RAPIDS
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:
1407919210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 S COLUMBIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-4039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-746-8374
Provider Business Mailing Address Fax Number:
701-780-0885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 PLEASANT AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56470-1415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-237-3052
Provider Business Practice Location Address Fax Number:
218-237-3055
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER, OFFICE MANAGER
Authorized Official Telephone Number:
701-746-8374

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 370068100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 183H5SE . This is a "BCBS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 64-07686 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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