Provider Demographics
NPI:1023032703
Name:CLUB RECOVERY LLC
Entity Type:Organization
Organization Name:CLUB RECOVERY LLC
Other - Org Name:CLUB RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ORRIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:TIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:BD
Authorized Official - Phone:952-926-2526
Mailing Address - Street 1:6550 YORK AVE S
Mailing Address - Street 2:SUITE 620
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2347
Mailing Address - Country:US
Mailing Address - Phone:952-926-2526
Mailing Address - Fax:952-926-6791
Practice Address - Street 1:6550 YORK AVE S
Practice Address - Street 2:SUITE 620
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2347
Practice Address - Country:US
Practice Address - Phone:952-926-2526
Practice Address - Fax:952-926-6791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10043993CDT261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN97283OtherHEALTH PARTNERS
MN8447176OtherUNITED BEHAVIORAL HEALTH
MN8447177OtherUNITED BEHAVIORAL HEALTH
MN8468358OtherUNITED BEHAVIORAL HEALTH
MN8448321OtherUNITED BEHAVIORAL HEALTH
MN4D24CLOtherBLUE CROSS BLUE SHIELD
MN8448324OtherUNITED BEHAVIORAL HEALTH
MN164215OtherUCARE OF MN
MN8448323OtherUNITED BEHAVIORAL HEALTH
MN8448322OtherUNITED BEHAVIORAL HEALTH
MN97283OtherHEALTH PARTNERS