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NPI Code Detail

MEDICARE: WILD RECOVERY LLC

MEDICARE: WILD RECOVERY 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
1251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1659245330
Entity Type Code : Organization
Provider Name (Legal Business Name) : WILD RECOVERY LLC
Provider Business Mailing Address
First Line : 1250 MOORE LAKE DR E
Second Line :
City : FRIDLEY
State : MN
Zip : 55432-5134
Country : US
Telephone Number : 612-201-2280
Fax Number : 612-465-2096
Provider Business Practice Location Address
First Line : 1250 MOORE LAKE DR E STE 210
Second Line :
City : FRIDLEY
State : MN
Zip : 55432-5135
Country : US
Telephone Number : 612-201-2280
Fax Number : 612-465-2096
Authorized Official
Title or Position : CEO
Name : TRACY LEE/ALVIN DOERR
Credential : LPCC, LADC
Telephone Number : 612-201-2280
Provider Enumeration Date : 10/03/2025
Last Update Date : 01/13/2026

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Directions to “WILD RECOVERY LLC ” Practice Location

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