Provider Demographics
NPI:1811245137
Name:CIRCLE BACK CENTER
Entity type:Organization
Organization Name:CIRCLE BACK CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:TONIHKA
Authorized Official - Suffix:I
Authorized Official - Credentials:CADC III, ICADC
Authorized Official - Phone:218-983-3285
Mailing Address - Street 1:35708 CO. HWY. 21
Mailing Address - Street 2:P.O. BOX 418
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591
Mailing Address - Country:US
Mailing Address - Phone:218-983-3285
Mailing Address - Fax:218-983-3027
Practice Address - Street 1:35708 CO. HWY. 21
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569-9998
Practice Address - Country:US
Practice Address - Phone:218-983-3285
Practice Address - Fax:218-983-3027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0008251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health