Organization
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Organization subpart
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Provider details
NPI number
Authorized official
JAN JOHNSON LADC (DIRECTOR)
(218) 894-0034
Entity
Organization
Contact information
Practice address
201 6TH ST NE, STAPLES, MN 56479-2431
(218) 894-0034
(218) 894-0035
Mailing address
201 6TH ST NE, STAPLES, MN 56479-2431
(218) 894-0034
(218) 894-0035
Taxonomy
Speciality
Code
Description
License number
State
3245S0500X
Children's Substance Abuse Rehabilitation Facility
Primary
1002834
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
943140300
STATE PROVIDER NUMBER
MN
Enumeration date
11/16/2006
Last updated
07/23/2008
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