MEDICARE: MINDFUL RECOVERY SERVICES 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1811754831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL RECOVERY SERVICES LLC

Provider Business Mailing Address
First Line	:	151 SILVER LAKE RD NW UNIT 6
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-8101
Country	:	US
Telephone Number	:	612-261-9312
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 SILVER LAKE RD NW UNIT 6
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-8101
Country	:	US
Telephone Number	:	612-261-9312
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ABDIRIZAK ALI ISMAIL
Credential	:
Telephone Number	:	612-261-9312

Provider Enumeration Date	:	03/05/2024
Last Update Date	:	03/05/2024

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