Healthcare Provider Details

I. General information

NPI: 1568978138
Provider Name (Legal Business Name): WILLISTON PARKS AND RECREATION DEPT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 02/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 18TH ST E
WILLISTON ND
58801-4475
US

IV. Provider business mailing address

PO BOX 1153
WILLISTON ND
58802-1153
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-9773
  • Fax:
Mailing address:
  • Phone: 701-774-9773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DARIN LINCOLN KRUEGER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 701-774-9773