Provider Demographics
NPI:1851900484
Name:IRON RANGE BEHAVIORAL SERVICES, LLC
Entity Type:Organization
Organization Name:IRON RANGE BEHAVIORAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:WICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-341-8523
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:COTTON
Mailing Address - State:MN
Mailing Address - Zip Code:55724-0236
Mailing Address - Country:US
Mailing Address - Phone:218-341-8523
Mailing Address - Fax:218-212-3444
Practice Address - Street 1:910 8TH ST S STE B
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-3236
Practice Address - Country:US
Practice Address - Phone:218-748-8500
Practice Address - Fax:218-748-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health