Provider Demographics
NPI:1679988109
Name:WILD RIVER SERVICES
Entity type:Organization
Organization Name:WILD RIVER SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:651-558-9522
Mailing Address - Street 1:1246 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4125
Mailing Address - Country:US
Mailing Address - Phone:651-558-9522
Mailing Address - Fax:
Practice Address - Street 1:796 CAPITOL HTS
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-1852
Practice Address - Country:US
Practice Address - Phone:651-558-9522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
324500000X
MN1084357324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility