Provider Demographics
NPI:1629169008
Name:WEST RIVER HEALTH SERVICES
Entity Type:Organization
Organization Name:WEST RIVER HEALTH SERVICES
Other - Org Name:WEST RIVER FOOT AND ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-567-6184
Mailing Address - Street 1:1000 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:HETTINGER
Mailing Address - State:ND
Mailing Address - Zip Code:58639-7530
Mailing Address - Country:US
Mailing Address - Phone:701-567-4561
Mailing Address - Fax:701-567-6361
Practice Address - Street 1:683 STATE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4660
Practice Address - Country:US
Practice Address - Phone:701-483-4561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid
NDN8755Medicare PIN