Provider Demographics
NPI:1992456073
Name:IMAGINE NATION LLC
Entity type:Organization
Organization Name:IMAGINE NATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:HERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-266-8082
Mailing Address - Street 1:417 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-1653
Mailing Address - Country:US
Mailing Address - Phone:320-266-8082
Mailing Address - Fax:
Practice Address - Street 1:3333 W DIVISION ST STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4555
Practice Address - Country:US
Practice Address - Phone:320-266-8082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMAGINE NATION LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty