Provider Demographics
NPI:1578621579
Name:MINNESOTA INDIAN PRIMARY RESIDENTIAL TREATMENT CENTER, INC.
Entity Type:Organization
Organization Name:MINNESOTA INDIAN PRIMARY RESIDENTIAL TREATMENT CENTER, INC.
Other - Org Name:MASH-KA-WISEN TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MALLERY II
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-879-6731
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:SAWYER
Mailing Address - State:MN
Mailing Address - Zip Code:55780-0066
Mailing Address - Country:US
Mailing Address - Phone:218-879-6731
Mailing Address - Fax:218-879-6734
Practice Address - Street 1:1150 MISSION RD
Practice Address - Street 2:
Practice Address - City:SAWYER
Practice Address - State:MN
Practice Address - Zip Code:55780-0066
Practice Address - Country:US
Practice Address - Phone:218-879-6731
Practice Address - Fax:218-879-6734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5013717OtherMEDICA
MN111904OtherUCARE
MN8103MAOtherBCBS OF MINNESOTA
MN9825MAOtherBCBS OF MINNESOTA