Healthcare Provider Details

I. General information

NPI: 1083437073
Provider Name (Legal Business Name): TREE MOIRE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N 42ND AVE.. SUITE# 002
MPLS MN
55412-5541
US

IV. Provider business mailing address

705 N 42ND AVE.. SUITE# 002
MPLS MN
55412
US

V. Phone/Fax

Practice location:
  • Phone: 763-290-2736
  • Fax: 612-605-0139
Mailing address:
  • Phone: 763-290-2736
  • Fax: 612-605-0139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY S POWELL
Title or Position: PRESIDENT
Credential: ADC-T, CPRS
Phone: 763-290-2736