Healthcare Provider Details

I. General information

NPI: 1144400011
Provider Name (Legal Business Name): RIVER OF LIFE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 EXCELSIOR BLVD #202
ST LOUIS PARK MN
55416-2730
US

IV. Provider business mailing address

6200 EXCELSIOR BLVD #202
ST LOUIS PARK MN
55416-2730
US

V. Phone/Fax

Practice location:
  • Phone: 952-548-9344
  • Fax: 952-548-9344
Mailing address:
  • Phone: 952-548-9344
  • Fax: 952-548-9344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number45852
License Number StateMN

VIII. Authorized Official

Name: DR. HAYDEN DONALDSON SEVERIN
Title or Position: ADDICTIONOLOGY/ASAM CERTIFIED
Credential: MD
Phone: 952-548-9344