Healthcare Provider Details

I. General information

NPI: 1205932233
Provider Name (Legal Business Name): HEART RIVER ALCOHOL AND DRUG ABUSE SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 12/10/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST JOE'S PLAZA 30 7TH ST W
DICKINSON ND
58601-4335
US

IV. Provider business mailing address

ST JOE'S PLAZA 30 7TH ST W
DICKINSON ND
58601-4335
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-0795
  • Fax: 701-483-0947
Mailing address:
  • Phone: 701-483-0795
  • Fax: 701-483-0947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1071
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1071
License Number StateND

VIII. Authorized Official

Name: MR. JOHN H. WIEGLENDA
Title or Position: LAC
Credential: LAC
Phone: 701-483-0795