NPIMap

Organization Active NPI

Selah Wellness Clinic LLC

  • Nurse Practitioner
  • Pine City, MN
National Provider Identifier
1104513126
Registry record updated May 31, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
Legal business name
SELAH WELLNESS CLINIC LLC
Practice address
1300 Northridge CT NW
Pine City, MN 55063-5821
Phone
(320) 372-2323
NPI assigned
Apr 19, 2023
Last updated
May 31, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 31, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tina Keller
Title
VP Compliance
Phone
(320) 372-2323

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X Primary

Addresses

Primary practice location

1300 Northridge CT NW
Pine City, MN 55063-5821

Mailing address

501 Main St
Sandstone, MN 55072-4410
Phone (320) 372-2323

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220718001776 MN Part B Supplier - Clinic/Group Practice 5597146852 Receives reassigned benefits from 11 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rush City, MN; Sandstone, MN; Pine City, MN; Mora, MN

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D2313654Selah Wellness Clinic LLC1300 Northridge Dr NW, Pine City, MN 55063Certificate of waiverNov 4, 2026

National Provider Directory

National Provider Directory
Tax ID family
Selah Wellness Clinic LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1300 Northridge Ct NW
Pine City, MN 55063
Phone (320) 372-2312

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/26347/brand/1/csg/1/fhir/r4

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1681862400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1780185600000",
    "number": "1104513126",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "501 MAIN ST",
            "city": "SANDSTONE",
            "state": "MN",
            "postal_code": "550724410",
            "telephone_number": "320-372-2323"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1300 NORTHRIDGE CT NW",
            "city": "PINE CITY",
            "state": "MN",
            "postal_code": "550635821",
            "telephone_number": "320-372-2323"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SELAH WELLNESS CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-04-19",
        "last_updated": "2026-05-31",
        "certification_date": "2026-05-31",
        "status": "A",
        "authorized_official_last_name": "KELLER",
        "authorized_official_first_name": "TINA",
        "authorized_official_title_or_position": "VP COMPLIANCE",
        "authorized_official_telephone_number": "320-372-2323"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pine City, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 31, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.