Provider Demographics
NPI:1316753908
Name:NELLY CARE CENTER LLC
Entity type:Organization
Organization Name:NELLY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JARGBAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-242-5770
Mailing Address - Street 1:6412 JUNE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2127
Mailing Address - Country:US
Mailing Address - Phone:612-552-1090
Mailing Address - Fax:
Practice Address - Street 1:6412 JUNE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2127
Practice Address - Country:US
Practice Address - Phone:612-552-1090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility