Basic Information
| Provider Information | |||||||||
| NPI: | 1922184167 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAKOTA BOYS & GIRLS RANCH ASSOCIATION | ||||||||
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| OtherOrganizationName: | DAKOTA BOYS RANCH FARGO RTC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7151 15TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58104 | ||||||||
| 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: | 10/31/2006 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | GANTZER | ||||||||
| AuthorizedOfficialFirstName: | SHONDELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCIAL SERVICES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7018580115 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | BLUE CROSS | OTHER | 50521 | 05 | ND | MEDICAID |