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General NPI Number Information
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NPI Number | 1578621579
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Entity Type | Organization
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Legal Business Name | MINNESOTA INDIAN PRIMARY RESIDENTIAL TREATMENT CENTER, INC.
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1150 MISSION RD
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City | SAWYER
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State | MN
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Zip | 55780-0066
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Country | US
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Telephone | 218-879-6731
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Fax | 218-879-6734
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Provider Business Mailing Address
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Address Line | PO BOX 66
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City | SAWYER
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State | MN
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Zip | 55780-0066
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Country | US
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Telephone | 218-879-6731
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Fax | 218-879-6734
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MR. JAMES W MALLERY II
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Credential |
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Telephone | 218-879-6731
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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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