1174974877 NPI number — RED RIVER BEHAVIORAL HEALTH SYSTEM

Table of content: (NPI 1174974877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174974877 NPI number — RED RIVER BEHAVIORAL HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED RIVER BEHAVIORAL HEALTH SYSTEM
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:
1174974877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 250, CONTRACTING/CREDENTIALING
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-326-7575
Provider Business Mailing Address Fax Number:
612-454-2430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1451 44TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-3434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-772-2500
Provider Business Practice Location Address Fax Number:
701-757-1512
Provider Enumeration Date:
06/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
612-326-7575

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 273R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 354005 . This is a "PART A" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: N724902 . This is a "PART B" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 1470202 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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