Healthcare Provider Details

I. General information

NPI: 1396780946
Provider Name (Legal Business Name): OMADA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 DIVISION ST S SUITE A
NORTHFIELD MN
55057-2095
US

IV. Provider business mailing address

401 DIVISION ST S SUITE A
NORTHFIELD MN
55057-2095
US

V. Phone/Fax

Practice location:
  • Phone: 507-664-9407
  • Fax: 507-664-3862
Mailing address:
  • Phone: 507-664-9407
  • Fax: 507-664-3862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1023523-2-CDT
License Number StateMN

VIII. Authorized Official

Name: MS. CAROLYN B GREEN
Title or Position: BUSINESS MANAGER
Credential: CPA
Phone: 507-664-9407