MEDICARE: JUEL FAIRBANKS CHEMICAL DEPENDENCY SERVICES

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
1	324500000X	Substance Abuse Rehabilitation Facility	803854-3-CDT	MN

General Provider Information

NPI Number	:	1649440355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUEL FAIRBANKS CHEMICAL DEPENDENCY SERVICES

Provider Business Mailing Address
First Line	:	806 ALBERT ST N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-1303
Country	:	US
Telephone Number	:	651-644-6204
Fax Number	:	651-644-1126

Provider Business Practice Location Address
First Line	:	806 ALBERT ST N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-1303
Country	:	US
Telephone Number	:	651-644-6204
Fax Number	:	651-644-1126

Authorized Official
Title or Position	:	EXECUTIVE DIRECOTR
Name	:	MRS. JANICE LINDSTROM
Credential	:
Telephone Number	:	651-644-6204

Provider Enumeration Date	:	03/10/2008
Last Update Date	:	03/10/2008

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