Provider Demographics
NPI:1982190773
Name:EAGAN HOPE WELLNESS SERVICES LLC
Entity Type:Organization
Organization Name:EAGAN HOPE WELLNESS SERVICES LLC
Other - Org Name:EAGAN HOPE WELLNESS SERVICES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AEYSHA
Authorized Official - Middle Name:NMI
Authorized Official - Last Name:NUR
Authorized Official - Suffix:
Authorized Official - Credentials:PROVIDER
Authorized Official - Phone:651-239-8745
Mailing Address - Street 1:4706 BRISTOL BLVD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-3989
Mailing Address - Country:US
Mailing Address - Phone:651-239-8745
Mailing Address - Fax:
Practice Address - Street 1:4651 NICOLS RD STE 206
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3424
Practice Address - Country:US
Practice Address - Phone:514-522-2876
Practice Address - Fax:651-454-8328
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health