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General NPI Number Information
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NPI Number | 1184171753
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Entity Type | Organization
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Legal Business Name | DAKOTA RENAISSANCE, INC.
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Dates
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Enumeration Date | 09/01/2016
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 101 3RD AVE # 44
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City | PETTIBONE
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State | ND
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Zip | 58475
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Country | US
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Telephone | 701-273-6688
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Fax | 888-972-4098
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Provider Business Mailing Address
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Address Line | 101 3RD AVE P.O. BOX 44
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City | PETTIBONE
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State | ND
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Zip | 58475
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Country | US
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Telephone | 701-273-6688
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Fax | 888-972-4098
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. SCHARAZARD LEE GRAY
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Credential | M.D.
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Telephone | 813-310-9346
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1100X
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Taxonomy Name | Research Clinic/Center
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License Number | 12015
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 12015
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License Number State | ND
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