Provider Demographics
NPI:1659926681
Name:FAA ADDICTION SERVICES
Entity Type:Organization
Organization Name:FAA ADDICTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHONDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-720-2964
Mailing Address - Street 1:900 N BROADWAY STE 111
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2378
Mailing Address - Country:US
Mailing Address - Phone:701-537-4191
Mailing Address - Fax:
Practice Address - Street 1:900 N BROADWAY STE 111
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2378
Practice Address - Country:US
Practice Address - Phone:701-537-4191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-06
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND159488Medicaid