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General NPI Number Information
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NPI Number | 1437872660
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Entity Type | Organization
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Legal Business Name | ABRIA DETOX LLC
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Dates
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Enumeration Date | 09/22/2022
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Last Update Date | 09/30/2023
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Provider Practice Location Address
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Address Line | 14750 LAC LAVON DR
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City | BURNSVILLE
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State | MN
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Zip | 55306-6398
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Country | US
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Telephone | 612-562-0561
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 654
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City | LAKEVILLE
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State | MN
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Zip | 55044-0654
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Country | US
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Telephone | 612-562-0561
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | IDMAN AHMEDNUR MOHAMED
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Credential |
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Telephone | 952-388-7640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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