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General NPI Number Information
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NPI Number | 1790589430
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Entity Type | Organization
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Legal Business Name | AWAKEN LIFE RECOVERY, LLC
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Dates
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Enumeration Date | 04/02/2025
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Last Update Date | 04/02/2025
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Provider Practice Location Address
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Address Line | 8150 20TH ST SE
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City | BUFFALO
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State | MN
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Zip | 55313-4640
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Country | US
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Telephone | 844-815-7625
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Fax |
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Provider Business Mailing Address
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Address Line | 2556 WESTVIEW TER
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City | MINNETONKA
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State | MN
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Zip | 55305-3118
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | KENNETH WILSON
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Credential |
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Telephone | 612-802-3646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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