Healthcare Provider Details

I. General information

NPI: 1306308101
Provider Name (Legal Business Name): SUMMIT SILVER CREEK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 11/15/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 125 T AVE NW
WATFORD CITY ND
58854
US

IV. Provider business mailing address

2046 125 T AVE NW
WATFORD CITY ND
58854
US

V. Phone/Fax

Practice location:
  • Phone: 732-580-1732
  • Fax: 701-597-3004
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW D'ALESSANDRO
Title or Position: MANAGING PARTNER
Credential:
Phone: 732-580-1732