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NPI Code Detail

MEDICARE: MRS. RITA MARIE CANNONWOLF B.A, T-ADC

MEDICARE: MRS. RITA MARIE CANNONWOLF B.A, T-ADC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1324500000XSubstance Abuse Rehabilitation FacilityMN

General Provider Information

NPI Number : 1093928459
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. RITA MARIE CANNONWOLF B.A, T-ADC
Provider Business Mailing Address
First Line : 222 9TH AVE W
Second Line :
City : ALEXANDRIA
State : MN
Zip : 56308-2221
Country : US
Telephone Number : 320-763-3912
Fax Number : 320-763-6629
Provider Business Practice Location Address
First Line : 222 9TH AVE W
Second Line :
City : ALEXANDRIA
State : MN
Zip : 56308-2221
Country : US
Telephone Number : 320-763-3912
Fax Number : 320-763-6629
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/08/2007
Last Update Date : 07/08/2007

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