| Organization Name: | CLUB RECOVERY LLC |
| NPI Number: | 1023032703 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ORRIN R. TIETZ (ADMINISTRATIVE DIRECTOR) |
| Mailing Address: | 6550 York Ave S Suite 620 Edina |
| State: | MN US |
| Postal Code: | 554352347 |
| Phone Number: | 9529262526 |
| Fax Number: | 9529266791 |
| NPI Enumeration Date: | 07/27/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR0405X |
| License Number: | 10043993CDT |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rehabilitation, Substance Use Disorder |
| Taxonomy Definition: | |