1023032703 NPI number — CLUB RECOVERY LLC

Table of content: (NPI 1023032703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023032703 NPI number — CLUB RECOVERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLUB RECOVERY 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:
Provider Other Organization Name Type Code:
6
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:
1023032703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6550 YORK AVE S
Provider Second Line Business Mailing Address:
SUITE 620
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-2347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-926-2526
Provider Business Mailing Address Fax Number:
952-926-6791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6550 YORK AVE S
Provider Second Line Business Practice Location Address:
SUITE 620
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-2347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-926-2526
Provider Business Practice Location Address Fax Number:
952-926-6791
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TIETZ
Authorized Official First Name:
ORRIN
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
952-926-2526

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  10043993CDT , 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: 97283 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8447176 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8447177 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8468358 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8448321 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4D24CL . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8448324 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 164215 . This is a "UCARE OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8448323 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8448322 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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