Provider Demographics
NPI:1053478164
Name:LEECH LAKE OPIATE TREATMENT PROGRAM
Entity Type:Organization
Organization Name:LEECH LAKE OPIATE TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUFFALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-335-8304
Mailing Address - Street 1:115 6TH ST NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3428
Mailing Address - Country:US
Mailing Address - Phone:218-335-4514
Mailing Address - Fax:218-335-4580
Practice Address - Street 1:110 BALSAM AVE. NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-4514
Practice Address - Fax:218-335-4580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization