Provider Demographics
NPI:1467501627
Name:PEACE GARDEN MULTI-DISTRICT COOPERATIVE
Entity Type:Organization
Organization Name:PEACE GARDEN MULTI-DISTRICT COOPERATIVE
Other - Org Name:PEACE GARDEN SPECIAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-228-3743
Mailing Address - Street 1:309 2ND ST E
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-1104
Mailing Address - Country:US
Mailing Address - Phone:701-228-3743
Mailing Address - Fax:701-228-3365
Practice Address - Street 1:309 2ND ST E
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318-1104
Practice Address - Country:US
Practice Address - Phone:701-228-3743
Practice Address - Fax:701-228-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19019225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19019Medicaid