Healthcare Provider Details

I. General information

NPI: 1184990608
Provider Name (Legal Business Name): STANDING ROCK EARLY CHILDHOOD TRACKING PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

001 STANDING ROCK AVENUE
FT. YATES ND
58538
US

IV. Provider business mailing address

PO BOX 697
FT. YATES ND
58538
US

V. Phone/Fax

Practice location:
  • Phone: 701-854-3678
  • Fax:
Mailing address:
  • Phone: 701-854-3678
  • Fax: 701-854-7181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number551
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateND

VIII. Authorized Official

Name: MR. GEORGE D STARR
Title or Position: DIRECTOR
Credential:
Phone: 701-854-3678