1376633743 NPI number — ADDICTION COUNSELING TREATMENT SERVICES

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 1376633743 NPI number — ADDICTION COUNSELING TREATMENT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADDICTION COUNSELING TREATMENT SERVICES
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:
Provider Other Organization Name Type Code:
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:
1376633743
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 5TH ST.
Provider Second Line Business Mailing Address:
P.O. BOX 700
Provider Business Mailing Address City Name:
GAYLORD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-238-2716
Provider Business Mailing Address Fax Number:
507-237-2736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 5TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAYLORD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-238-2716
Provider Business Practice Location Address Fax Number:
507-237-2736
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUESGEN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
507-237-2716

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  10422051CDT , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 340090500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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