Provider Demographics
NPI:1437872660
Name:ABRIA DETOX LLC
Entity Type:Organization
Organization Name:ABRIA DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IDMAN
Authorized Official - Middle Name:AHMEDNUR
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-388-7640
Mailing Address - Street 1:PO BOX 654
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-0654
Mailing Address - Country:US
Mailing Address - Phone:612-562-0561
Mailing Address - Fax:
Practice Address - Street 1:14750 LAC LAVON DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-6398
Practice Address - Country:US
Practice Address - Phone:612-562-0561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2023-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility