Provider Demographics
NPI:1902325426
Name:RED LAKE MEDICATION ASSISTED RECOVERY SERVICES
Entity Type:Organization
Organization Name:RED LAKE MEDICATION ASSISTED RECOVERY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SALENA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-1543
Mailing Address - Street 1:P.O. BOX 114
Mailing Address - Street 2:
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3996
Mailing Address - Fax:217-679-3976
Practice Address - Street 1:24760 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3995
Practice Address - Fax:218-679-3976
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RED LAKE MEDICATION ASSISTED RECOVERY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1002OtherTRIBAL LICENSE