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General NPI Number Information
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NPI Number | 1427611318
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Entity Type | Organization
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Legal Business Name | PROVISION WELLNESS CENTER LLC
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Dates
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Enumeration Date | 04/17/2019
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Last Update Date | 04/02/2026
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Provider Practice Location Address
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Address Line | 4001 STINSON BLVD SUITE 300
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City | ST. ANTHONY
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State | MN
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Zip | 55421-3488
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Country | US
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Telephone | 612-401-1786
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Fax |
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Provider Business Mailing Address
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Address Line | 4001 STINSON BLVD NE STE 300
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City | MINNEAPOLIS
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State | MN
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Zip | 55421-3424
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Country | US
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Telephone | 612-401-1786
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARYAN FARAH
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Credential |
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Telephone | 612-401-1786
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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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