Healthcare Provider Details

I. General information

NPI: 1326053166
Provider Name (Legal Business Name): FOND DU LAC RESERVATION BUSINESS COMMITTEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 TRETTLE LANE FOND DU LAC HUMAN SERVICES DIVISION
CLOQUET MN
55720
US

IV. Provider business mailing address

927 TRETTLE LANE FOND DU LAC HUMAN SERVICES DIVISION
CLOQUET MN
55720
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-1227
  • Fax: 218-878-3800
Mailing address:
  • Phone: 218-879-1227
  • Fax: 218-878-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5985000001
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number012003
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: MS. MARILYN GROVER
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 218-879-1227