Provider Demographics
NPI:1376310847
Name:PRISTINE MENTAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:PRISTINE MENTAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-246-2851
Mailing Address - Street 1:1053 GRAND AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1053 GRAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3074
Practice Address - Country:US
Practice Address - Phone:651-246-2851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center