Provider Demographics
NPI:1093814576
Name:MAPLE LKE RECOVERY CENTER INC
Entity Type:Organization
Organization Name:MAPLE LKE RECOVERY CENTER INC
Other - Org Name:PRAIRIE HOUSE RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:FEENSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:BS LADC
Authorized Official - Phone:612-501-1197
Mailing Address - Street 1:207 DIVISION ST. E.
Mailing Address - Street 2:BOX 308
Mailing Address - City:MAPLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55358
Mailing Address - Country:US
Mailing Address - Phone:320-963-6865
Mailing Address - Fax:
Practice Address - Street 1:305 PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8990
Practice Address - Country:US
Practice Address - Phone:651-785-5647
Practice Address - Fax:763-295-9579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1032184-1-CRF3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children