Healthcare Provider Details

I. General information

NPI: 1700394640
Provider Name (Legal Business Name): RED LAKE CHEMICAL HEALTH PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15797 MAIN AVE
RED LAKE MN
56671-0114
US

IV. Provider business mailing address

P.O. BOX 114
RED LAKE MN
56671
US

V. Phone/Fax

Practice location:
  • Phone: 218-679-3331
  • Fax: 218-679-3302
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: REYNA CRUZ GONZALEZ-RIVERA
Title or Position: PROJECT DIRECTOR
Credential:
Phone: 218-679-3392