MEDICARE: NOLANEDNA RECOVERY LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1639020605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOLANEDNA RECOVERY LIVING LLC

Provider Business Mailing Address
First Line	:	3503 LONG BRANCH AVE
Second Line	:
City	:	WILLISTON
State	:	ND
Zip	:	58801-2982
Country	:	US
Telephone Number	:	701-609-3917
Fax Number	:

Provider Business Practice Location Address
First Line	:	3503 LONG BRANCH AVE
Second Line	:
City	:	WILLISTON
State	:	ND
Zip	:	58801-2982
Country	:	US
Telephone Number	:	701-609-3917
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CLARA LENA CHIMOMBE
Credential	:
Telephone Number	:	701-609-3917

Provider Enumeration Date	:	02/05/2026
Last Update Date	:	02/05/2026

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