Provider Demographics
NPI:1376030700
Name:NIVON WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:NIVON WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/TREATMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BILLINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:612-564-8073
Mailing Address - Street 1:7501 80TH ST S STE 108
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4121
Mailing Address - Country:US
Mailing Address - Phone:612-564-8073
Mailing Address - Fax:
Practice Address - Street 1:7501 80TH ST S STE 108 & 200
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4121
Practice Address - Country:US
Practice Address - Phone:612-564-8073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-20
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X
MN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health