Provider Demographics
NPI:1144400011
Name:RIVER OF LIFE SERVICES LLC
Entity Type:Organization
Organization Name:RIVER OF LIFE SERVICES LLC
Other - Org Name:RIVER OF LIFE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADDICTIONOLOGY/ASAM CERTIFIED
Authorized Official - Prefix:DR
Authorized Official - First Name:HAYDEN
Authorized Official - Middle Name:DONALDSON
Authorized Official - Last Name:SEVERIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-548-9344
Mailing Address - Street 1:6200 EXCELSIOR BLVD
Mailing Address - Street 2:#202
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2730
Mailing Address - Country:US
Mailing Address - Phone:952-548-9344
Mailing Address - Fax:952-548-9344
Practice Address - Street 1:6200 EXCELSIOR BLVD
Practice Address - Street 2:#202
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2730
Practice Address - Country:US
Practice Address - Phone:952-548-9344
Practice Address - Fax:952-548-9344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45852207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB15531Medicare UPIN
MNC04215Medicare PIN