Healthcare Provider Details

I. General information

NPI: 1750467999
Provider Name (Legal Business Name): DAKOTA BOYS & GIRLS RANCH ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 19TH AVE NW
MINOT ND
58703
US

IV. Provider business mailing address

6301 19TH AVE NW
MINOT ND
58703
US

V. Phone/Fax

Practice location:
  • Phone: 701-858-0115
  • Fax:
Mailing address:
  • Phone: 701-858-0115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier54725
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: SHONDELL GANTZER
Title or Position: BOOKKEEPER
Credential:
Phone: 701-858-0115