MEDICARE: EMBARK REENTRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1164239489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMBARK REENTRY LLC

Provider Business Mailing Address
First Line	:	8716 ELLIOT AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-3024
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8716 ELLIOT AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-3024
Country	:	US
Telephone Number	:	612-636-3060
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ABDALLA ALI
Credential	:
Telephone Number	:	612-636-3060

Provider Enumeration Date	:	12/11/2024
Last Update Date	:	02/09/2026

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Directions to “EMBARK REENTRY LLC ” Practice Location

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