Healthcare Provider Details

I. General information

NPI: 1679988109
Provider Name (Legal Business Name): WILD RIVER SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

796 CAPITOL HTS
SAINT PAUL MN
55103-1852
US

IV. Provider business mailing address

1246 UNIVERSITY AVE W SUITE 101
SAINT PAUL MN
55104-4125
US

V. Phone/Fax

Practice location:
  • Phone: 651-558-9522
  • Fax:
Mailing address:
  • Phone: 651-558-9522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1084357
License Number StateMN

VIII. Authorized Official

Name: COLIN KELLY FAULKNER II
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 651-558-9522