Provider Demographics
NPI:1629471099
Name:COCHRAN RECOVERY SERVICES, INC.
Entity Type:Organization
Organization Name:COCHRAN RECOVERY SERVICES, INC.
Other - Org Name:COCHRAN OUT PATIENT PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:TERZICK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:651-437-4209
Mailing Address - Street 1:1294 18TH ST E
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-3680
Mailing Address - Country:US
Mailing Address - Phone:651-437-4209
Mailing Address - Fax:651-438-4144
Practice Address - Street 1:310 VERMILLION ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-1237
Practice Address - Country:US
Practice Address - Phone:651-438-2639
Practice Address - Fax:651-438-2752
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COCHRAN RECOVERY SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-30
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN80061110CDT261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1629471099Medicaid
MN1821491465Medicaid
MN1134394828Medicaid