Provider Demographics
NPI:1003332057
Name:RED LAKE DETENTION OUTPATIENT
Entity Type:Organization
Organization Name:RED LAKE DETENTION OUTPATIENT
Other - Org Name:RED LAKE DETENTION OUTPATIENT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROJECT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:REYNA
Authorized Official - Middle Name:CRUZ
Authorized Official - Last Name:GONZALEZ-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-3392
Mailing Address - Street 1:P.O. BOX 114
Mailing Address - Street 2:
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3995
Mailing Address - Fax:218-679-3976
Practice Address - Street 1:25064 HIGHWAY 1 EAST
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3995
Practice Address - Fax:218-679-3976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-21
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1001OtherTRIBAL LICENSE