Healthcare Provider Details

I. General information

NPI: 1164239489
Provider Name (Legal Business Name): EMBARK REENTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8716 ELLIOT AVE S
BLOOMINGTON MN
55420-3024
US

IV. Provider business mailing address

8716 ELLIOT AVE S
BLOOMINGTON MN
55420-3024
US

V. Phone/Fax

Practice location:
  • Phone: 612-636-3060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ABDALLA ALI
Title or Position: OWNER
Credential:
Phone: 612-636-3060