Healthcare Provider Details

I. General information

NPI: 1184171753
Provider Name (Legal Business Name): DAKOTA RENAISSANCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 3RD AVE # 44
PETTIBONE ND
58475
US

IV. Provider business mailing address

101 3RD AVE P.O. BOX 44
PETTIBONE ND
58475
US

V. Phone/Fax

Practice location:
  • Phone: 701-273-6688
  • Fax: 888-972-4098
Mailing address:
  • Phone: 701-273-6688
  • Fax: 888-972-4098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number12015
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number12015
License Number StateND

VIII. Authorized Official

Name: DR. SCHARAZARD LEE GRAY
Title or Position: DIRECTOR
Credential: M.D.
Phone: 813-310-9346