Healthcare Provider Details

I. General information

NPI: 1194490763
Provider Name (Legal Business Name): ANISHINAABE ENDAAD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2021
Last Update Date: 08/14/2021
Certification Date: 08/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 2ND ST NW
MAHNOMEN MN
56557-4316
US

IV. Provider business mailing address

3529 ZENITH AVE N
ROBBINSDALE MN
55422-2347
US

V. Phone/Fax

Practice location:
  • Phone: 612-208-6613
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ADAM FAIRBANKS
Title or Position: PRINCIPAL
Credential:
Phone: 612-208-6613