Basic Information
| Provider Information | |||||||||
| NPI: | 1801209697 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REWIND, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PERHAM | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565731934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183466100 | ||||||||
| FaxNumber: | 2183466112 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PERHAM | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565731934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183466100 | ||||||||
| FaxNumber: | 2183466112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | HOLM | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 2183466100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LADC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 10348381CDT | MN | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 302032 | 01 | MN | LADC LICENSE | OTHER |