| Vlw Llc | |
|
4255 Pheasant Ridge Dr Ne Ste 412 Blaine MN 55449-5066 | |
| (612) 799-6652 | |
| Not Available |
| Full Name | Vlw Llc |
|---|---|
| Speciality | Clinic/center - Mental Health (including Community Mental Health Center) |
| Location | 4255 Pheasant Ridge Dr Ne Ste 412, Blaine, Minnesota |
| Authorized Official Name and Position | Amanda Adell Wirth (CEO) |
| Authorized Official Contact | 6127996652 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Vlw Llc 8578 Dunkirk Ct Ne Blaine MN 55449-6789 Ph: (612) 799-6652 | Vlw Llc 4255 Pheasant Ridge Dr Ne Ste 412 Blaine MN 55449-5066 Ph: (612) 799-6652 |
| NPI Number | 1336628478 |
|---|---|
| Provider Enumeration Date | 08/09/2018 |
| Last Update Date | 11/17/2021 |
| Certification Date | 11/17/2021 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336628478 | NPI | - | NPPES |
| 5724462 | Medicaid | MN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | 3061 (Minnesota) | Primary |
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