Provider Demographics
NPI:1821485178
Name:LONE WOLF RECOVERY
Entity Type:Organization
Organization Name:LONE WOLF RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:YUREK
Authorized Official - Suffix:
Authorized Official - Credentials:BA, LADC
Authorized Official - Phone:320-485-2323
Mailing Address - Street 1:PO BOX 163
Mailing Address - Street 2:471 2ND ST N
Mailing Address - City:WINSTED
Mailing Address - State:MN
Mailing Address - Zip Code:55395
Mailing Address - Country:US
Mailing Address - Phone:320-485-2323
Mailing Address - Fax:320-485-4585
Practice Address - Street 1:471 2ND ST N
Practice Address - Street 2:
Practice Address - City:WINSTED
Practice Address - State:MN
Practice Address - Zip Code:55395
Practice Address - Country:US
Practice Address - Phone:320-485-2323
Practice Address - Fax:320-485-4585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1074872-1-CDT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health