Healthcare Provider Details

I. General information

NPI: 1982922324
Provider Name (Legal Business Name): JUEL FAIRBANKS CHEMICAL DEPENDENCY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 ALBERT ST N
SAINT PAUL MN
55104
US

IV. Provider business mailing address

806 ALBERT ST N
SAINT PAUL MN
55104-1303
US

V. Phone/Fax

Practice location:
  • Phone: 651-282-0460
  • Fax: 651-644-1126
Mailing address:
  • Phone: 651-282-0460
  • Fax: 651-644-1126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number803854-3-CDT
License Number StateMN

VIII. Authorized Official

Name: JANICE LINDSTROM
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 651-282-0460