Provider Demographics
NPI:1760587109
Name:MAPLE LAKE RECOVERY CENTER, INC.
Entity Type:Organization
Organization Name:MAPLE LAKE RECOVERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:FEENSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:612-501-1197
Mailing Address - Street 1:P O BOX 308
Mailing Address - Street 2:207 DIVISION ST. E
Mailing Address - City:MAPLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55358
Mailing Address - Country:US
Mailing Address - Phone:320-963-6865
Mailing Address - Fax:320-963-6279
Practice Address - Street 1:207 DIVISION ST. E
Practice Address - Street 2:
Practice Address - City:MAPLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55358
Practice Address - Country:US
Practice Address - Phone:320-963-6865
Practice Address - Fax:320-963-6279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN810975-1-CRF3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children