Provider Demographics
NPI:1184017279
Name:ALLIANCE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:ALLIANCE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:YUSSUF
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFIE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LGSW
Authorized Official - Phone:952-992-9803
Mailing Address - Street 1:1120 E 80TH ST STE 108
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-1463
Mailing Address - Country:US
Mailing Address - Phone:952-992-9803
Mailing Address - Fax:
Practice Address - Street 1:1120 E 80TH ST STE 108
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1463
Practice Address - Country:US
Practice Address - Phone:952-992-9803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1077449261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder