Provider Demographics
NPI:1851419345
Name:RANGE MENTAL HEALTH CENTER INC
Entity Type:Organization
Organization Name:RANGE MENTAL HEALTH CENTER INC
Other - Org Name:DETOX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:MSED, LP
Authorized Official - Phone:218-749-2881
Mailing Address - Street 1:624 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792
Mailing Address - Country:US
Mailing Address - Phone:218-749-2881
Mailing Address - Fax:218-749-3806
Practice Address - Street 1:626 S 13TH ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-741-9120
Practice Address - Fax:218-741-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3L52RAOtherBLUE CROSS BLUE SHIELD
MN5042378OtherMEDICA
MN3L52RAOtherBLUE CROSS BLUE SHIELD