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General NPI Number Information
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NPI Number | 1467961193
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Entity Type | Organization
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Legal Business Name | WILD RIVER SERVICES INC
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Dates
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Enumeration Date | 09/26/2017
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Last Update Date | 07/10/2018
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Provider Practice Location Address
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Address Line | 1394 JACKSON ST
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City | SAINT PAUL
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State | MN
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Zip | 55117
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Country | US
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Telephone | 651-558-9522
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Fax |
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Provider Business Mailing Address
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Address Line | 1394 JACKSON ST STE 300
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City | SAINT PAUL
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State | MN
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Zip | 55117-4629
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Country | US
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Telephone | 651-558-9522
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Fax | 651-207-1771
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | COLIN FAULKNER
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Credential |
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Telephone | 651-558-9522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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