Provider Demographics
NPI:1689894263
Name:STATE OF NORTH DAKOTA
Entity Type:Organization
Organization Name:STATE OF NORTH DAKOTA
Other - Org Name:DIVISION OF JUVENILE SERVICES, DOCR
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BJERGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-328-6674
Mailing Address - Street 1:3100 RAILROAD AVE
Mailing Address - Street 2:PO BOX 1898
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-1898
Mailing Address - Country:US
Mailing Address - Phone:701-328-6674
Mailing Address - Fax:
Practice Address - Street 1:3100 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58502-1898
Practice Address - Country:US
Practice Address - Phone:701-328-6674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NORTH DAKOTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-26
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51517Medicaid