Provider Demographics
NPI:1609947985
Name:NORTHWEST RECOVERY CENTER
Entity Type:Organization
Organization Name:NORTHWEST RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LADC
Authorized Official - Phone:218-681-6561
Mailing Address - Street 1:115 6TH ST W
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-1511
Mailing Address - Country:US
Mailing Address - Phone:218-681-6561
Mailing Address - Fax:218-681-0477
Practice Address - Street 1:115 6TH ST W
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-1511
Practice Address - Country:US
Practice Address - Phone:218-681-6561
Practice Address - Fax:218-681-0477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
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
MN1030141OtherPREFERRED ONE
MN167478OtherUCARE
MN5087964OtherMEDICA
MN4271NOOtherMN BLUE CROSS
MN4271NOOtherMN BLUE PLUS