Healthcare Provider Details

I. General information

NPI: 1093814576
Provider Name (Legal Business Name): MAPLE LKE RECOVERY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 PRAIRIE RD
MONTICELLO MN
55362-8990
US

IV. Provider business mailing address

207 DIVISION ST. E. BOX 308
MAPLE LAKE MN
55358
US

V. Phone/Fax

Practice location:
  • Phone: 651-785-5647
  • Fax: 763-295-9579
Mailing address:
  • Phone: 320-963-6865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number1032184-1-CRF
License Number StateMN

VIII. Authorized Official

Name: JUDITH M FEENSTRA
Title or Position: ADMINISTRATOR
Credential: BS LADC
Phone: 612-501-1197