Healthcare Provider Details

I. General information

NPI: 1558635128
Provider Name (Legal Business Name): WENDEN OLMSTED COUNTY CORRECTION RECOVERY SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 4TH ST SE
ROCHESTER MN
55904-3752
US

IV. Provider business mailing address

217 PLUM ST #220
RED WING MN
55066-2351
US

V. Phone/Fax

Practice location:
  • Phone: 651-385-0600
  • Fax: 651-388-2129
Mailing address:
  • Phone: 651-385-0600
  • Fax: 651-388-2129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1061701-1CDT
License Number StateMN

VIII. Authorized Official

Name: MR. ADAM GARCIA
Title or Position: OWNER
Credential: LADC
Phone: 651-385-0600