Basic Information
| Provider Information | |||||||||
| NPI: | 1831271808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAKOTA BOYS & GIRLS RANCH ASSOCATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAKOTA BOYS RANCH FARGO YOUTH HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1641 31ST AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581035934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018580115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6301 19TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018580115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | GANTZER | ||||||||
| AuthorizedOfficialFirstName: | SHONDELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | BOOKKEEPER | ||||||||
| AuthorizedOfficialTelephone: | 7018580115 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | ND | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 244003 | 01 | ND | BLUE SHIELD | OTHER | 54715 | 05 | ND | MEDICAID |