Provider Demographics
NPI:1275942666
Name:BETHER 4 ACRES
Entity Type:Organization
Organization Name:BETHER 4 ACRES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:KAE
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-320-2649
Mailing Address - Street 1:PO BOX 1835
Mailing Address - Street 2:1404 1ST AVE N
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401
Mailing Address - Country:US
Mailing Address - Phone:701-252-6090
Mailing Address - Fax:
Practice Address - Street 1:1404 1ST AVE N
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-2379
Practice Address - Country:US
Practice Address - Phone:701-252-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8020305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service