Basic Information
| Provider Information | |||||||||
| NPI: | 1972099240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW BEGINNINGS WAVERLY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN ST STE 190 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551123271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124542046 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7300 ESTES AVE SW | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553908432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636585800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2018 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | ASPER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CONTRACTING, CREDENTIAL | ||||||||
| AuthorizedOfficialTelephone: | 6124542046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERIDIAN BEHAVIORAL HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 1089815-3-SUDX | MN | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.