Provider Demographics
NPI:1568752533
Name:RUM RIVER HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:RUM RIVER HEALTH SERVICES, INC.
Other - Org Name:MEN'S RESIDENCE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-389-5080
Mailing Address - Street 1:101 18TH AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-4756
Mailing Address - Country:US
Mailing Address - Phone:763-389-5080
Mailing Address - Fax:763-631-9117
Practice Address - Street 1:3079 90TH AVENUE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371
Practice Address - Country:US
Practice Address - Phone:763-389-5080
Practice Address - Fax:763-631-9117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNFBL-4868-25062276400000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility