Healthcare Provider Details

I. General information

NPI: 1720222334
Provider Name (Legal Business Name): RIDGEWOOD RECOVERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W SUPERIOR ST. SUITE 700
DULUTH MN
55802
US

IV. Provider business mailing address

202 W SUPERIOR ST. SUITE 700
DULUTH MN
55802
US

V. Phone/Fax

Practice location:
  • Phone: 218-336-9300
  • Fax: 715-392-8041
Mailing address:
  • Phone: 218-336-9300
  • Fax: 715-392-8041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1052968
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KATHY M FETSCH
Title or Position: DIRECTOR
Credential:
Phone: 715-392-9300