Provider Demographics
NPI:1114527322
Name:4TH CORPORAITON
Entity Type:Organization
Organization Name:4TH CORPORAITON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KODI
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-947-2147
Mailing Address - Street 1:120 11TH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:NEW ROCKFORD
Mailing Address - State:ND
Mailing Address - Zip Code:58356
Mailing Address - Country:US
Mailing Address - Phone:701-947-2147
Mailing Address - Fax:
Practice Address - Street 1:1006 2ND AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:NEW ROCKFORD
Practice Address - State:ND
Practice Address - Zip Code:58356
Practice Address - Country:US
Practice Address - Phone:701-947-2147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health