Provider Demographics
NPI:1881950285
Name:ALLIANCE CLINIC, LLC
Entity type:Organization
Organization Name:ALLIANCE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BERYIMAR
Authorized Official - Middle Name:HAIDIBIT
Authorized Official - Last Name:PEROZO-TREJO
Authorized Official - Suffix:
Authorized Official - Credentials:BS, LADC
Authorized Official - Phone:612-454-2260
Mailing Address - Street 1:3329 UNIVERSITY AVENUE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-454-2260
Mailing Address - Fax:612-454-2340
Practice Address - Street 1:3329 UNIVERSITY AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3325
Practice Address - Country:US
Practice Address - Phone:612-454-2260
Practice Address - Fax:612-454-2340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303178251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management