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General NPI Number Information
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NPI Number | 1013816677
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Entity Type | Organization
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Legal Business Name | PROVIDENCE SERVICES MN LLC
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Dates
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Enumeration Date | 11/02/2026
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Last Update Date | 11/02/2026
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Provider Practice Location Address
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Address Line | 566 EDMUND AVE
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City | SAINT PAUL
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State | MN
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Zip | 55103-1682
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Country | US
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Telephone | 651-442-9485
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Fax | 651-369-5600
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Provider Business Mailing Address
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Address Line | 566 EDMUND AVE APT 3
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City | SAINT PAUL
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State | MN
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Zip | 55103-1683
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Country | US
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Telephone | 651-442-9485
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Fax | 651-369-5600
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Authorized Official
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Title or Position | OWNER
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Name | DOMINIC IRABOR
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Credential | NP
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Telephone | 651-334-2100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State |
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