Provider Demographics
NPI:1407235575
Name:COAL COUNTRY COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:COAL COUNTRY COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-873-4445
Mailing Address - Street 1:150 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KILLDEER
Mailing Address - State:ND
Mailing Address - Zip Code:58640-4018
Mailing Address - Country:US
Mailing Address - Phone:701-764-5822
Mailing Address - Fax:
Practice Address - Street 1:150 CENTRAL AVE N
Practice Address - Street 2:
Practice Address - City:KILLDEER
Practice Address - State:ND
Practice Address - Zip Code:58640-4018
Practice Address - Country:US
Practice Address - Phone:701-764-5822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1464996Medicaid
ND1464996Medicaid
ND351818Medicare Oscar/Certification