1578070991 NPI number — RED LAKE CHEMICAL HEALTH PROGRAMS

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 1578070991 NPI number — RED LAKE CHEMICAL HEALTH PROGRAMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED LAKE CHEMICAL HEALTH PROGRAMS
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:
6
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:
1578070991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 114
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15566 DAKOTA AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDBY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-679-3387
Provider Business Practice Location Address Fax Number:
218-679-2375
Provider Enumeration Date:
01/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ-RIVERA
Authorized Official First Name:
REYNA
Authorized Official Middle Name:
CRUZ
Authorized Official Title or Position:
PROJECT DIRECTOR
Authorized Official Telephone Number:
218-679-3392

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 649755100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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