Basic Information
| Provider Information | |||||||||
| NPI: | 1306945209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OMEGON, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 HOPKINS XRD | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553052500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525414738 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DANIELSON | ||||||||
| AuthorizedOfficialFirstName: | BARB | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE/CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9525414738 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
ID Information
| ID | Type | State | Issuer | Description | 18386 | 01 | HEALTH PARTNERS | OTHER | 8513OM | 01 | MN | BCBS | OTHER |