Healthcare Provider Details

I. General information

NPI: 1245318377
Provider Name (Legal Business Name): THRIVE BEHAVIORAL NETWORK IV, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 9TH AVE WEST
ALEXANDRIA MN
56308-2204
US

IV. Provider business mailing address

107 DOCTORS PARK
ST CLOUD MN
56303-1207
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-3912
  • Fax: 320-763-6629
Mailing address:
  • Phone: 320-255-9530
  • Fax: 320-251-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1036409
License Number StateMN

VIII. Authorized Official

Name: JEFF BRADLEY
Title or Position: PRESIDENT
Credential:
Phone: 320-763-3912