MEDICARE: WARRIOR DOWN - PEER RECOVERY SUPPORT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility
2	332800000X	Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1001	OTHER	MN	TRIBAL LICENSE

General Provider Information

NPI Number	:	1003332057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WARRIOR DOWN - PEER RECOVERY SUPPORT

Provider Business Mailing Address
First Line	:	P.O. BOX 114
Second Line	:
City	:	RED LAKE
State	:	MN
Zip	:	56671
Country	:	US
Telephone Number	:	218-679-3995
Fax Number	:	218-679-3976

Provider Business Practice Location Address
First Line	:	15533 MAIN AVENUE
Second Line	:
City	:	RED LAKE
State	:	MN
Zip	:	56671-0114
Country	:	US
Telephone Number	:	218-679-3392
Fax Number	:

Authorized Official
Title or Position	:	ADMIN OFFICER
Name	:	MS. SALENA BEASLEY
Credential	:
Telephone Number	:	218-679-3392

Provider Enumeration Date	:	08/21/2017
Last Update Date	:	11/27/2024

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