Provider Demographics
NPI:1649401357
Name:LEECH LAKE OPIATE TREATMENT CENTER
Entity Type:Organization
Organization Name:LEECH LAKE OPIATE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:218-335-8304
Mailing Address - Street 1:115 6TH ST. NW
Mailing Address - Street 2:LEECH LAKE BAND OF OJIBWE #E
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3428
Mailing Address - Country:US
Mailing Address - Phone:218-335-8200
Mailing Address - Fax:218-335-4580
Practice Address - Street 1:108 BALSAM
Practice Address - Street 2:LEECH OPIATE TREATMENT CENTER
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3428
Practice Address - Country:US
Practice Address - Phone:218-335-8304
Practice Address - Fax:218-335-4580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEECH LAKE BAND OF OJIBWE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN05125302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization