Healthcare Provider Details

I. General information

NPI: 1750773693
Provider Name (Legal Business Name): BHG XL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 N BROADWAY
ROCHESTER MN
55906-4065
US

IV. Provider business mailing address

8300 DOUGLAS AVE SUITE 750
DALLAS TX
75225-5603
US

V. Phone/Fax

Practice location:
  • Phone: 507-282-0142
  • Fax: 507-282-6261
Mailing address:
  • Phone: 214-365-6100
  • Fax: 214-365-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. DEREK WALSH
Title or Position: VP OPS ADMIN
Credential:
Phone: 214-365-6100