Healthcare Provider Details

I. General information

NPI: 1932629078
Provider Name (Legal Business Name): INDEPENDENT HEALTHCARE RESOURCES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 DUNLAP ST N STE 820
SAINT PAUL MN
55104-4343
US

IV. Provider business mailing address

10 7TH AVE N APT 208
HOPKINS MN
55343-8843
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-1090
  • Fax: 651-645-5168
Mailing address:
  • Phone: 612-607-4421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HIRSI OMAR
Title or Position: TREATMENT DIRECTOR
Credential:
Phone: 612-607-4421