Healthcare Provider Details

I. General information

NPI: 1780186130
Provider Name (Legal Business Name): ALLIANCE WELLNESS CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8040 OLD CEDAR AVE. S. STE. 100
BLOOMINGTON MN
55425-1211
US

IV. Provider business mailing address

8040 OLD CEDAR AVE. S. STE. 100
BLOOMINGTON MN
55425-1211
US

V. Phone/Fax

Practice location:
  • Phone: 952-693-0080
  • Fax: 952-955-6567
Mailing address:
  • Phone: 952-693-0080
  • Fax: 952-955-6567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: MS. PATRICIA JOANN FRIEDMAN
Title or Position: TREATMENT DIRECTOR
Credential: LADC
Phone: 952-693-0080