Provider Demographics
NPI:1528930906
Name:IRIDESCENT CARE COLLABORATIVE LLC
Entity type:Organization
Organization Name:IRIDESCENT CARE COLLABORATIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MERRIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-484-6897
Mailing Address - Street 1:3754 PLEASANT AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-1279
Mailing Address - Country:US
Mailing Address - Phone:952-484-6897
Mailing Address - Fax:
Practice Address - Street 1:3754 PLEASANT AVE STE 205
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-1279
Practice Address - Country:US
Practice Address - Phone:952-484-6897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty