1063613438 NPI number — COUNTY OF DICKEY

Table of content: (NPI 1063613438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063613438 NPI number — COUNTY OF DICKEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF DICKEY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063613438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 238
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENDALE
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58436-0238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-349-4348
Provider Business Mailing Address Fax Number:
701-349-3277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 15TH STREET NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLENDALE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-349-4348
Provider Business Practice Location Address Fax Number:
701-349-3277
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOLM
Authorized Official First Name:
ROXANNE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
701-349-4348

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , with the licence number:  AN7413254 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 51756 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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