Provider Demographics
NPI:1982922324
Name:JUEL FAIRBANKS CHEMICAL DEPENDENCY SERVICES
Entity Type:Organization
Organization Name:JUEL FAIRBANKS CHEMICAL DEPENDENCY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-282-0460
Mailing Address - Street 1:806 ALBERT ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1303
Mailing Address - Country:US
Mailing Address - Phone:651-282-0460
Mailing Address - Fax:651-644-1126
Practice Address - Street 1:804 ALBERT ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-282-0460
Practice Address - Fax:651-644-1126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN803854-3-CDT261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)