Healthcare Provider Details

I. General information

NPI: 1588672034
Provider Name (Legal Business Name): WESMAR OF INTERNATIONAL FALLS MN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 5TH ST SUITE 101
INTERNATIONAL FALLS MN
56649-2217
US

IV. Provider business mailing address

PO BOX 593 SUITE 101
INTERNATIONAL FALLS MN
56649-0593
US

V. Phone/Fax

Practice location:
  • Phone: 218-285-7029
  • Fax: 218-285-7072
Mailing address:
  • Phone: 218-285-7029
  • Fax: 218-285-7072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number10371421CDT
License Number StateMN

VIII. Authorized Official

Name: MR. WESLEY BUTTS
Title or Position: OWNER
Credential: LADC
Phone: 218-285-7029