Provider Demographics
NPI:1316151335
Name:AVALON - PINE CITY
Entity type:Organization
Organization Name:AVALON - PINE CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-326-7555
Mailing Address - Street 1:550 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3271
Mailing Address - Country:US
Mailing Address - Phone:612-326-7555
Mailing Address - Fax:
Practice Address - Street 1:655 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1443
Practice Address - Country:US
Practice Address - Phone:612-326-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1034226101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty