Healthcare Provider Details

I. General information

NPI: 1205683570
Provider Name (Legal Business Name): PATHWAY TO RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 20TH AVE S
MINNEAPOLIS MN
55404-2212
US

IV. Provider business mailing address

900 20TH AVE S
MINNEAPOLIS MN
55404-2212
US

V. Phone/Fax

Practice location:
  • Phone: 612-205-1113
  • Fax:
Mailing address:
  • Phone: 612-205-1113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: SADIK ALI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 612-205-1113