Provider Demographics
NPI:1881802411
Name:RED LAKE CHEMICAL HEALTH PROGRAMS OUTPATIENT
Entity type:Organization
Organization Name:RED LAKE CHEMICAL HEALTH PROGRAMS OUTPATIENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANGER
Authorized Official - Prefix:
Authorized Official - First Name:SALENA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRANCHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-3392
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:
Mailing Address - City:REDLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0114
Mailing Address - Country:US
Mailing Address - Phone:218-679-3392
Mailing Address - Fax:218-679-3976
Practice Address - Street 1:15797 MAIN AVE
Practice Address - Street 2:HWY 1
Practice Address - City:REDLAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-0114
Practice Address - Country:US
Practice Address - Phone:218-679-3392
Practice Address - Fax:218-679-3976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN627635100Medicaid