Basic Information
| Provider Information | |||||||||
| NPI: | 1376501262 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAKOTA BOYS & GIRLS RANCH ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5007 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587025007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018397888 | ||||||||
| FaxNumber: | 7018521190 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 19TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587038824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018397888 | ||||||||
| FaxNumber: | 7018521190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | GANTZER | ||||||||
| AuthorizedOfficialFirstName: | SHONDELL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BOOKKEEPER | ||||||||
| AuthorizedOfficialTelephone: | 7018580115 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | ND | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 10348 | 01 | ND | FARGO RTC | OTHER | 52146 | 05 | ND | MEDICAID | 3913 | 01 | ND | DAKOTA BOYS RANCH | OTHER | 54725 | 05 | ND | MEDICAID | 12344 | 01 | ND | WESTERN PLAINS | OTHER | 18078 | 05 | ND | MEDICAID | 50521 | 05 | ND | MEDICAID | 54715 | 05 | ND | MEDICAID | 54730 | 05 | ND | MEDICAID | 57550 | 05 | ND | MEDICAID | 54710 | 05 | ND | MEDICAID |