Healthcare Provider Details

I. General information

NPI: 1750559035
Provider Name (Legal Business Name): 4TH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 11TH ST N
NEW ROCKFORD ND
58356-1434
US

IV. Provider business mailing address

120 11TH ST N
NEW ROCKFORD ND
58356-1434
US

V. Phone/Fax

Practice location:
  • Phone: 701-947-2147
  • Fax:
Mailing address:
  • Phone: 701-947-2147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberND01161
License Number StateND

VIII. Authorized Official

Name: KODI KELLER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 701-947-2147