Provider Demographics
NPI:1588732762
Name:MINNESOTA INDIAN PRIMARY RESIDENTIAL TREATMENT CENTER, INC.
Entity type:Organization
Organization Name:MINNESOTA INDIAN PRIMARY RESIDENTIAL TREATMENT CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MALLERY
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:218-879-6731
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:SAWYER
Mailing Address - State:MN
Mailing Address - Zip Code:55780
Mailing Address - Country:US
Mailing Address - Phone:218-879-6731
Mailing Address - Fax:218-879-6734
Practice Address - Street 1:9302 IDAHO STREET
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55808
Practice Address - Country:US
Practice Address - Phone:218-727-7699
Practice Address - Fax:218-727-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2023-05-08
Deactivation Date:2008-06-25
Deactivation Code:
Reactivation Date:2009-08-17
Provider Licenses
StateLicense IDTaxonomies
MN8025091CDT177F00000X
177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes177F00000XOther Service ProvidersLodgingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9594THOtherBCBS OF MINNESOTA
MN786355100Medicaid