Provider Demographics
NPI:1376501262
Name:DAKOTA BOYS & GIRLS RANCH ASSOCIATION
Entity Type:Organization
Organization Name:DAKOTA BOYS & GIRLS RANCH ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHONDELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GANTZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-858-0115
Mailing Address - Street 1:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5007
Mailing Address - Country:US
Mailing Address - Phone:701-839-7888
Mailing Address - Fax:701-852-1190
Practice Address - Street 1:6301 19TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-8824
Practice Address - Country:US
Practice Address - Phone:701-839-7888
Practice Address - Fax:701-852-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10348OtherFARGO RTC
ND52146Medicaid
ND3913OtherDAKOTA BOYS RANCH
ND54725Medicaid
ND12344OtherWESTERN PLAINS
ND18078Medicaid
ND50521Medicaid
ND54715Medicaid
ND54730Medicaid
ND57550Medicaid
ND54710Medicaid