Provider Demographics
NPI:1689698193
Name:MCKENZIE COUNTY HEALTHCARE SYSTEMS INC
Entity Type:Organization
Organization Name:MCKENZIE COUNTY HEALTHCARE SYSTEMS INC
Other - Org Name:GOOD SHEPHERD HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-842-3000
Mailing Address - Street 1:709 4TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-7628
Mailing Address - Country:US
Mailing Address - Phone:701-444-2331
Mailing Address - Fax:701-444-4629
Practice Address - Street 1:709 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7628
Practice Address - Country:US
Practice Address - Phone:701-444-2331
Practice Address - Fax:701-444-4629
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCKENZIE COUNTY HEALTHCARE SYSTEMS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-27
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30767Medicaid