Provider Demographics
NPI:1891948238
Name:PIONEER RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:PIONEER RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/CO-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:NYAKUNDI
Authorized Official - Suffix:
Authorized Official - Credentials:LADC, CADC III
Authorized Official - Phone:218-393-1421
Mailing Address - Street 1:5388 ROAD 37
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705-8338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5388 ROAD 37
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705-8338
Practice Address - Country:US
Practice Address - Phone:218-393-1421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility