=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932629078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDEPENDENT HEALTHCARE RESOURCES, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2017
-----------------------------------------------------
Last Update Date | 06/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 393 DUNLAP ST N STE 820
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-645-1090
-----------------------------------------------------
Fax | 651-645-5168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 7TH AVE N APT 208
-----------------------------------------------------
City | HOPKINS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55343-8843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-607-4421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREATMENT DIRECTOR
-----------------------------------------------------
Name | HIRSI OMAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-607-4421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------