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General NPI Number Information
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NPI Number | 1548050461
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Entity Type | Organization
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Legal Business Name | DICKINSON COUNTRYHOUSE LLC
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Dates
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Enumeration Date | 05/12/2025
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Last Update Date | 05/23/2025
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Provider Practice Location Address
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Address Line | 628 24TH ST W
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City | DICKINSON
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State | ND
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Zip | 58601-2731
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Country | US
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Telephone | 701-847-0842
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Fax |
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Provider Business Mailing Address
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Address Line | 17110 MARCY ST STE LL01
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City | OMAHA
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State | NE
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Zip | 68118-3119
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Country | US
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Telephone | 531-800-3364
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Fax | 531-800-3364
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Authorized Official
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Title or Position | VP ASSET MANAGEMENT
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Name | STACY RANDELS
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Credential |
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Telephone | 531-800-3364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number |
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License Number State |
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