Provider Demographics
NPI:1417577693
Name:PRAIRIE GRIT ADAPTIVE SPORTS
Entity Type:Organization
Organization Name:PRAIRIE GRIT ADAPTIVE SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:RENE'
Authorized Official - Last Name:BUTGEREIT
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR/L
Authorized Official - Phone:208-949-3315
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-0969
Mailing Address - Country:US
Mailing Address - Phone:208-949-3315
Mailing Address - Fax:
Practice Address - Street 1:3515 16TH ST SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7225
Practice Address - Country:US
Practice Address - Phone:208-949-3315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty