Healthcare Provider Details

I. General information

NPI: 1629544267
Provider Name (Legal Business Name): GOOD ROAD RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 ELBOWOOD LN
BISMARCK ND
58503-5712
US

IV. Provider business mailing address

1308 ELBOWOOD LN
BISMARCK ND
58503-5712
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-8260
  • Fax:
Mailing address:
  • Phone: 701-751-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SHERRY MICHELLE BAKER
Title or Position: BILLING SPECIALIST
Credential: CPC
Phone: 701-751-8260