Provider Demographics
NPI:1629544267
Name:GOOD ROAD RECOVERY CENTER
Entity Type:Organization
Organization Name:GOOD ROAD RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:701-751-8260
Mailing Address - Street 1:1308 ELBOWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5712
Mailing Address - Country:US
Mailing Address - Phone:701-751-8260
Mailing Address - Fax:
Practice Address - Street 1:1308 ELBOWOOD LN
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5712
Practice Address - Country:US
Practice Address - Phone:701-751-8260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE AFFILIATED TRIBES CENTRAL FINANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodgingGroup - Single Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTIN