Provider Demographics
NPI:1245754548
Name:QUENTIN N BURDICK COMPREHENSIVE HEALTH CARE FACILITY
Entity Type:Organization
Organization Name:QUENTIN N BURDICK COMPREHENSIVE HEALTH CARE FACILITY
Other - Org Name:QUENTIN N BURDICK COMPREHENSIVE HEALTHCARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DELAND
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-477-6111
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-0160
Mailing Address - Country:US
Mailing Address - Phone:701-477-6111
Mailing Address - Fax:701-477-2500
Practice Address - Street 1:1 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316-0160
Practice Address - Country:US
Practice Address - Phone:701-477-6111
Practice Address - Fax:701-477-2500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUENTIN N BURDICK COMPREHENSIVE HEALTHCARE FACILITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1465304Medicaid