Healthcare Provider Details

I. General information

NPI: 1558495010
Provider Name (Legal Business Name): ALLIANCE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3329 UNIVERSITY AVE SE
MINNEAPOLIS MN
55414-3325
US

IV. Provider business mailing address

550 MAIN ST #230
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 612-638-2260
  • Fax: 612-638-2340
Mailing address:
  • Phone: 612-326-7600
  • Fax: 612-326-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1009916-2-CDT
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number1009916
License Number StateMN

VIII. Authorized Official

Name: JAY HIGHAM
Title or Position: CEO
Credential:
Phone: 214-365-6112