=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174974877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RED RIVER BEHAVIORAL HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2016
-----------------------------------------------------
Last Update Date | 07/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1451 44TH AVE S
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-772-2500
-----------------------------------------------------
Fax | 701-757-1512
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 MAIN STREET SUITE 250, CONTRACTING/CREDENTIALING
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-326-7575
-----------------------------------------------------
Fax | 612-454-2430
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATIVE OFFICER
-----------------------------------------------------
Name | MR. JAMES SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-326-7575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------