Healthcare Provider Details

I. General information

NPI: 1346351475
Provider Name (Legal Business Name): PRIDE MANCHESTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MISSOURI AVE
BISMARCK ND
58504-5264
US

IV. Provider business mailing address

1200 MISSOURI AVE
BISMARCK ND
58504-5264
US

V. Phone/Fax

Practice location:
  • Phone: 701-258-7838
  • Fax: 701-258-3735
Mailing address:
  • Phone: 701-258-7838
  • Fax: 701-258-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DARLA ROGGENBUCK
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 701-258-7838