Healthcare Provider Details

I. General information

NPI: 1003914656
Provider Name (Legal Business Name): NEW BEGININGS AT WAVERLY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N SHORE DR
WAVERLY MN
55390-5517
US

IV. Provider business mailing address

109 N SHORE DR
WAVERLY MN
55390-5517
US

V. Phone/Fax

Practice location:
  • Phone: 763-658-5800
  • Fax: 763-658-1746
Mailing address:
  • Phone: 763-658-5800
  • Fax: 763-658-1746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1003743-1-CDT
License Number StateMN

VIII. Authorized Official

Name: MRS. BRENDA GRIFFIN
Title or Position: CONTROLLER
Credential:
Phone: 763-658-5222