1588732762 NPI number — MINNESOTA INDIAN PRIMARY RESIDENTIAL TREATMENT CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588732762 NPI number — MINNESOTA INDIAN PRIMARY RESIDENTIAL TREATMENT CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA INDIAN PRIMARY RESIDENTIAL TREATMENT CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THUNDERBIRD-WREN HOUSE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588732762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/25/2008
NPI Reactivation Date:
08/17/2009

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 66
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAWYER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-879-6731
Provider Business Mailing Address Fax Number:
218-879-6734

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9302 IDAHO STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-727-7699
Provider Business Practice Location Address Fax Number:
218-727-1476
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALLERY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
W
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
218-879-6731

Provider Taxonomy Codes

  • Taxonomy code: 177F00000X , with the licence number:  8025091CDT , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 177F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9594TH . This is a "BCBS OF MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 786355100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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