Provider Demographics
NPI:1043219728
Name:NEW LIFE TREATMENT CENTER
Entity Type:Organization
Organization Name:NEW LIFE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WES
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN ESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-777-4321
Mailing Address - Street 1:130 DAKOTA ST S
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56186-1037
Mailing Address - Country:US
Mailing Address - Phone:507-777-4321
Mailing Address - Fax:507-777-4284
Practice Address - Street 1:130 DAKOTA ST S
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:MN
Practice Address - Zip Code:56186-1037
Practice Address - Country:US
Practice Address - Phone:507-777-4321
Practice Address - Fax:507-777-4284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN801702-3-CDT324500000X
MN1033814-1-DS324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility