Healthcare Provider Details

I. General information

NPI: 1518412907
Provider Name (Legal Business Name): ABINTRA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 98TH ST SUITE 107
BLOOMINGTON MN
55420-3820
US

IV. Provider business mailing address

PO BOX 113
CRYSTAL BAY MN
55323-0113
US

V. Phone/Fax

Practice location:
  • Phone: 612-968-6097
  • Fax: 612-435-9842
Mailing address:
  • Phone: 612-968-6097
  • Fax: 612-435-9842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14313
License Number StateMN

VIII. Authorized Official

Name: MR. JOHN OBRIEN
Title or Position: PRESIDENT
Credential: LICSW
Phone: 612-968-6097