Provider Demographics
NPI:1225386774
Name:1303 GROUP HOME
Entity Type:Organization
Organization Name:1303 GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:REMBOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-663-0379
Mailing Address - Street 1:201 4TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 7TH AVE SE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-4506
Practice Address - Country:US
Practice Address - Phone:701-663-0379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIT INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-15
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1456205Medicaid
ND30879Medicaid