Provider Demographics
NPI:1992213839
Name:RED LAKE CHEMICAL HEALTH PROGRAMS
Entity Type:Organization
Organization Name:RED LAKE CHEMICAL HEALTH PROGRAMS
Other - Org Name:PONEMAH OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PROJECT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REYNA
Authorized Official - Middle Name:CRUZ
Authorized Official - Last Name:GONZALEZ-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-3392
Mailing Address - Street 1:P.O. BOX 114
Mailing Address - Street 2:
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19195 NORTH PONEMAH ROAD
Practice Address - Street 2:
Practice Address - City:PONEMAH
Practice Address - State:MN
Practice Address - Zip Code:56666
Practice Address - Country:US
Practice Address - Phone:218-554-7425
Practice Address - Fax:218-554-7325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PONEMAH OUTPATIENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-12
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1004OtherTRIBAL LICENSE