Healthcare Provider Details

I. General information

NPI: 1184367567
Provider Name (Legal Business Name): PROVIDENCE HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2126 VISTA DR
ARNEGARD ND
58835
US

IV. Provider business mailing address

PO BOX 1286
WATFORD CITY ND
58854-1286
US

V. Phone/Fax

Practice location:
  • Phone: 701-586-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MORGAN LAYNE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 701-586-3300