Healthcare Provider Details

I. General information

NPI: 1023032703
Provider Name (Legal Business Name): CLUB RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 YORK AVE S SUITE 620
EDINA MN
55435-2347
US

IV. Provider business mailing address

6550 YORK AVE S SUITE 620
EDINA MN
55435-2347
US

V. Phone/Fax

Practice location:
  • Phone: 952-926-2526
  • Fax: 952-926-6791
Mailing address:
  • Phone: 952-926-2526
  • Fax: 952-926-6791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number10043993CDT
License Number StateMN

VIII. Authorized Official

Name: MR. ORRIN R. TIETZ
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: B.D.
Phone: 952-926-2526