MEDICARE: RED LAKE CHEMICAL HEALTH PROGRAMS OUTPATIENT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881802411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RED LAKE CHEMICAL HEALTH PROGRAMS OUTPATIENT

Provider Business Mailing Address
First Line	:	PO BOX 114
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0114
Country	:	US
Telephone Number	:	218-679-3392
Fax Number	:	218-679-3976

Provider Business Practice Location Address
First Line	:	15797 MAIN AVE
Second Line	:	HWY 1
City	:	REDLAKE
State	:	MN
Zip	:	56671-0114
Country	:	US
Telephone Number	:	218-679-3392
Fax Number	:	218-679-3976

Authorized Official
Title or Position	:	PROGRAM MANGER
Name	:	SALENA L BRANCHAUD
Credential	:
Telephone Number	:	218-679-3392

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	03/27/2019

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