Healthcare Provider Details

I. General information

NPI: 1558285221
Provider Name (Legal Business Name): ALEX KORDIAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4638 VICTOR PATH STE 900
HUGO MN
55038-4732
US

IV. Provider business mailing address

30569 RILEY LN
SHAFER MN
55074-2328
US

V. Phone/Fax

Practice location:
  • Phone: 651-364-3839
  • Fax:
Mailing address:
  • Phone: 763-248-5849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number307686
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: