Organization
RED LAKE CHEMICAL HEALTH PROGRAMS
Active
Parent organization
PONEMAH OUTPATIENT
Other names
Ponemah Outpatient
Organization subpart
Yes
Provider details
NPI number
Legal business name
PONEMAH OUTPATIENT
Authorized official
REYNA CRUZ GONZALEZ-RIVERA (PROJECT DIRECTOR)
(218) 679-3392
Entity
Organization
Contact information
Practice address
19195 NORTH PONEMAH ROAD, PONEMAH, MN 56666
(218) 554-7425
(218) 554-7325
Mailing address
P.O. BOX 114, RED LAKE, MN 56671
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
—
—
332800000X
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1004
TRIBAL LICENSE
MN
Enumeration date
01/12/2018
Last updated
03/20/2019
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