Healthcare Provider Details

I. General information

NPI: 1629532429
Provider Name (Legal Business Name): ECC ADDICTION & TOXICOLOGY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 UNIVERSITY AVE SE STE 730
MINNEAPOLIS MN
55414-3279
US

IV. Provider business mailing address

PO BOX 86 LOCK BOX 12-0910
MINNEAPOLIS MN
55486-0085
US

V. Phone/Fax

Practice location:
  • Phone: 612-439-1862
  • Fax:
Mailing address:
  • Phone: 612-439-1862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY GEDDES
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 612-439-1862