Healthcare Provider Details

I. General information

NPI: 1780423178
Provider Name (Legal Business Name): SERE PATH WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 5TH AVE S UNIT 120
MINNEAPOLIS MN
55415-1609
US

IV. Provider business mailing address

600 5TH AVE S UNIT 120
MINNEAPOLIS MN
55415-1609
US

V. Phone/Fax

Practice location:
  • Phone: 612-470-0667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FOLARIN ADEDEJI
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 612-460-1807