Provider Demographics
NPI:1558635128
Name:WENDEN OLMSTED COUNTY CORRECTION RECOVERY SERVICE
Entity Type:Organization
Organization Name:WENDEN OLMSTED COUNTY CORRECTION RECOVERY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:651-385-0600
Mailing Address - Street 1:217 PLUM ST
Mailing Address - Street 2:#220
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2351
Mailing Address - Country:US
Mailing Address - Phone:651-385-0600
Mailing Address - Fax:651-388-2129
Practice Address - Street 1:140 4TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-3752
Practice Address - Country:US
Practice Address - Phone:651-385-0600
Practice Address - Fax:651-388-2129
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WENDEN RECOVERY SERVICE. INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1061701-1CDT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN106170-1-CDTOtherDHS LICENSE NUMBER