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General NPI Number Information
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NPI Number | 1376030700
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Entity Type | Organization
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Legal Business Name | NIVON WELLNESS CENTER LLC
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Dates
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Enumeration Date | 04/20/2018
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Last Update Date | 09/30/2019
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Provider Practice Location Address
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Address Line | 7501 80TH ST S STE 108 & 200
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City | COTTAGE GROVE
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State | MN
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Zip | 55016-4121
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Country | US
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Telephone | 612-564-8073
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Fax |
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Provider Business Mailing Address
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Address Line | 7501 80TH ST S STE 108
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City | COTTAGE GROVE
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State | MN
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Zip | 55016-4121
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Country | US
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Telephone | 612-564-8073
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Fax |
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Authorized Official
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Title or Position | OWNER/TREATMENT DIRECTOR
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Name | NICOLE M BILLINGSLEY
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Credential | LADC
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Telephone | 612-564-8073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State | MN
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