Healthcare Provider Details

I. General information

NPI: 1417757329
Provider Name (Legal Business Name): HARVEST RIDGE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 3RD AVE SE
FAIRFAX MN
55332-4502
US

IV. Provider business mailing address

300 3RD AVE SE
FAIRFAX MN
55332-4502
US

V. Phone/Fax

Practice location:
  • Phone: 651-249-3034
  • Fax:
Mailing address:
  • Phone: 651-249-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: NICK MOTU
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 651-249-3034