Provider Demographics
NPI:1366681918
Name:PRAIRIE ST. JOHN'S, LLC
Entity Type:Organization
Organization Name:PRAIRIE ST. JOHN'S, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:EIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-476-7200
Mailing Address - Street 1:510 4TH ST. SOUTH
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:401-478-7517
Mailing Address - Fax:701-478-7524
Practice Address - Street 1:510 4TH ST. SOUTH
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:401-478-7517
Practice Address - Fax:701-478-7524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND597-1-1-08A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility