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General NPI Number Information
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NPI Number | 1982922324
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Entity Type | Organization
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Legal Business Name | JUEL FAIRBANKS CHEMICAL DEPENDENCY SERVICES
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Dates
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Enumeration Date | 05/10/2010
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Last Update Date | 05/10/2010
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Provider Practice Location Address
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Address Line | 804 ALBERT ST N
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City | SAINT PAUL
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State | MN
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Zip | 55104
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Country | US
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Telephone | 651-282-0460
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Fax | 651-644-1126
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Provider Business Mailing Address
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Address Line | 806 ALBERT ST N
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City | SAINT PAUL
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State | MN
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Zip | 55104-1303
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Country | US
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Telephone | 651-282-0460
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Fax | 651-644-1126
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JANICE LINDSTROM
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Credential |
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Telephone | 651-282-0460
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0401X
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Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
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License Number | 803854-3-CDT
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License Number State | MN
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