Provider Demographics
NPI:1740042654
Name:RED LAKE AVIVO SUD TRIBAL HEALTH SERVICES
Entity type:Organization
Organization Name:RED LAKE AVIVO SUD TRIBAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-1320
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:REDLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0566
Mailing Address - Country:US
Mailing Address - Phone:218-679-1320
Mailing Address - Fax:
Practice Address - Street 1:1900 CHICAGO AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-752-8106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility