Provider Demographics
NPI:1225335862
Name:FOND DU LAC RESERVATION BUSINESS COMMITTEE
Entity Type:Organization
Organization Name:FOND DU LAC RESERVATION BUSINESS COMMITTEE
Other - Org Name:FDL ADULT OUTPATIENT TX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-879-1227
Mailing Address - Street 1:927 TRETTEL LANE
Mailing Address - Street 2:FOND DU LAC HUMAN SERVICES DIVISION
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720
Mailing Address - Country:US
Mailing Address - Phone:218-879-1227
Mailing Address - Fax:218-878-3755
Practice Address - Street 1:927 TRETTEL LANE
Practice Address - Street 2:FOND DU LAC HUMAN SERVICES DIVISION
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:218-878-3755
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOND DU LAC HUMAN SERVICES DIVISION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-17
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN012010261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1326053166Medicaid
MN1326053166Medicaid