Healthcare Provider Details

I. General information

NPI: 1841658887
Provider Name (Legal Business Name): COAL COUNTRY COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 8TH AVE NW
HAZEN ND
58545-4638
US

IV. Provider business mailing address

1312 HIGHWAY 49 N
BEULAH ND
58523-6038
US

V. Phone/Fax

Practice location:
  • Phone: 701-748-2257
  • Fax: 701-749-2257
Mailing address:
  • Phone: 701-873-4445
  • Fax: 701-873-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DARROLD BERTSCH
Title or Position: CEO
Credential:
Phone: 701-873-4445