=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679758486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNE CARLSEN CENTER FOR CHILDREN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2007
-----------------------------------------------------
Last Update Date | 02/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 603 3RD ST NW
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58401-2965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-252-3850
-----------------------------------------------------
Fax | 701-952-5154
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 3RD ST NW
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58401-2963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-252-3850
-----------------------------------------------------
Fax | 701-952-5154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TIM EISSINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-952-5187
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------