1215377692 NPI number — NEXUS FAMILY HEALING

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 1215377692 NPI number — NEXUS FAMILY HEALING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEXUS FAMILY HEALING
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:
NEXUS-INDIAN OAKS FAMILY HEALING
Provider Other Organization Name Type Code:
5
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:
1215377692
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 HIGHWAY 169 N STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55441-6447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-551-8640
Provider Business Mailing Address Fax Number:
763-553-1637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 EVERGREEN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANTENO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-802-3700
Provider Business Practice Location Address Fax Number:
815-468-2320
Provider Enumeration Date:
06/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DUNNING
Authorized Official First Name:
JASON
Authorized Official Middle Name:
CLARK
Authorized Official Title or Position:
DIRECTOR OF FINANCIAL PLANNING
Authorized Official Telephone Number:
763-551-8664

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 322D00000X , with the licence number: 223668-06 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2B05-IPI-051 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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