Basic Information
| Provider Information | |||||||||
| NPI: | 1003914656 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW BEGININGS AT WAVERLY, LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 109 N SHORE DR | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553905517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636585800 | ||||||||
| FaxNumber: | 7636581746 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 N SHORE DR | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553905517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636585800 | ||||||||
| FaxNumber: | 7636581746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7636585222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 1003743-1-CDT | MN | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.