Provider Demographics
NPI:1245318377
Name:THRIVE BEHAVIORAL NETWORK IV, LLC
Entity type:Organization
Organization Name:THRIVE BEHAVIORAL NETWORK IV, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-763-3912
Mailing Address - Street 1:107 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1207
Mailing Address - Country:US
Mailing Address - Phone:320-255-9530
Mailing Address - Fax:320-251-2996
Practice Address - Street 1:222 9TH AVE WEST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2204
Practice Address - Country:US
Practice Address - Phone:320-763-3912
Practice Address - Fax:320-763-6629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1036409324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN674407901Medicaid