Healthcare Provider Details

I. General information

NPI: 1639851884
Provider Name (Legal Business Name): PATHWAY TO RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 10/11/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 20TH AVE S
MINNEAPOLIS MN
55404-2212
US

IV. Provider business mailing address

2750 CEDAR AVE S UNIT 103
MINNEAPOLIS MN
55407-1892
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 Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SADIK A ALI
Title or Position: CHIEF MANAGER
Credential: MD
Phone: 612-205-1113