Basic Information
| Provider Information | |||||||||
| NPI: | 1558495010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIANCE CLINIC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VALHALLA MINNEAPOLIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN ST | ||||||||
| Address2: | #230 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267600 | ||||||||
| FaxNumber: | 6123267549 | ||||||||
| Practice Location | |||||||||
| Address1: | 3329 UNIVERSITY AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554143325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126382260 | ||||||||
| FaxNumber: | 6126382340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 08/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6123267625 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERIDIAN BEHAVIORAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 1009916-2-CDT | MN | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 302R00000X | 1009916 | MN | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.