Healthcare Provider Details

I. General information

NPI: 1568752533
Provider Name (Legal Business Name): RUM RIVER HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3079 90TH AVENUE
PRINCETON MN
55371
US

IV. Provider business mailing address

101 18TH AVENUE NORTH
PRINCETON MN
55371-4756
US

V. Phone/Fax

Practice location:
  • Phone: 763-389-5080
  • Fax: 763-631-9117
Mailing address:
  • Phone: 763-389-5080
  • Fax: 763-631-9117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License NumberFBL-4868-25062
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberFBL-4868-25062
License Number StateMN

VIII. Authorized Official

Name: MR. JEFFREY LARSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 763-389-5080