MEDICARE: COMMUNITY MENTAL HEALTH 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	:	1972991669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY MENTAL HEALTH LLC

Provider Business Mailing Address
First Line	:	2533 24TH AVE S
Second Line	:	STE 2
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-4127
Country	:	US
Telephone Number	:	612-210-0377
Fax Number	:

Provider Business Practice Location Address
First Line	:	2533 24TH AVE S
Second Line	:	STE 2
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-4127
Country	:	US
Telephone Number	:	612-210-0377
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ABIB MUSSE
Credential	:
Telephone Number	:	612-309-4689

Provider Enumeration Date	:	01/03/2015
Last Update Date	:	01/03/2015

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