Basic Information
| Provider Information | |||||||||
| NPI: | 1306595236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIMBER WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7881 W CHARLESTON BLVD STE 230 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891178327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025082153 | ||||||||
| FaxNumber: | 7025082435 | ||||||||
| Practice Location | |||||||||
| Address1: | 13770 FRONTIER CT | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553374810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028482256 | ||||||||
| FaxNumber: | 7024856746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2022 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | REBMAN | ||||||||
| AuthorizedOfficialFirstName: | GLEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6309304014 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1487181558 | 05 | MN | MEDICAID |