Provider Demographics
NPI:1962899013
Name:ADDICTION CARE PHYSICIANS
Entity type:Organization
Organization Name:ADDICTION CARE PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:DR
Authorized Official - First Name:SIRRI
Authorized Official - Middle Name:ATANG
Authorized Official - Last Name:NOMO-ONGOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-788-2273
Mailing Address - Street 1:3616 ROOSEVELT ST NE
Mailing Address - Street 2:
Mailing Address - City:ST ANTHONY VILLAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1559
Mailing Address - Country:US
Mailing Address - Phone:612-788-2273
Mailing Address - Fax:612-886-1939
Practice Address - Street 1:4001 STINSON BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-3488
Practice Address - Country:US
Practice Address - Phone:612-788-2273
Practice Address - Fax:612-886-1939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000Other000000000