Provider Demographics
NPI:1124725361
Name:ENTWINE II LLC
Entity type:Organization
Organization Name:ENTWINE II LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:KELLER SALVAGGIO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:701-720-7222
Mailing Address - Street 1:3615 17TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-7050
Mailing Address - Country:US
Mailing Address - Phone:701-720-7222
Mailing Address - Fax:701-532-0428
Practice Address - Street 1:3505 8TH ST S STE 3
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5108
Practice Address - Country:US
Practice Address - Phone:701-532-0991
Practice Address - Fax:701-532-0428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-08
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty