Provider Demographics
NPI:1457688863
Name:RED CLIFF AODA PROGRAM/MISHOMIS HOUSE
Entity Type:Organization
Organization Name:RED CLIFF AODA PROGRAM/MISHOMIS HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:CSAC/ICS
Authorized Official - Phone:715-779-3741
Mailing Address - Street 1:88385 PIKE RD
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4818
Mailing Address - Country:US
Mailing Address - Phone:715-779-3741
Mailing Address - Fax:715-779-3765
Practice Address - Street 1:37390 N BRADUM RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4832
Practice Address - Country:US
Practice Address - Phone:715-779-3741
Practice Address - Fax:715-779-3765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1781261QR0405X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42128500Medicaid