Organization
CLUB RECOVERY LLC
Active
Other names
Club Recovery
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ORRIN R. TIETZ B.D. (ADMINISTRATIVE DIRECTOR)
(952) 926-2526
Entity
Organization
Contact information
Practice address
6550 YORK AVE S, SUITE 620, EDINA, MN 55435-2347
(952) 926-2526
(952) 926-6791
Mailing address
6550 YORK AVE S, SUITE 620, EDINA, MN 55435-2347
(952) 926-2526
(952) 926-6791
Taxonomy
Speciality
Code
Description
License number
State
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
10043993CDT
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
164215
UCARE OF MN
MN
01
—
4D24CL
BLUE CROSS BLUE SHIELD
MN
01
—
8447176
UNITED BEHAVIORAL HEALTH
MN
01
—
8447177
UNITED BEHAVIORAL HEALTH
MN
01
—
8448321
UNITED BEHAVIORAL HEALTH
MN
01
—
8448322
UNITED BEHAVIORAL HEALTH
MN
01
—
8448323
UNITED BEHAVIORAL HEALTH
MN
01
—
8448324
UNITED BEHAVIORAL HEALTH
MN
01
—
8468358
UNITED BEHAVIORAL HEALTH
MN
01
—
97283
HEALTH PARTNERS
MN
Enumeration date
07/27/2006
Last updated
08/22/2020
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