Provider Demographics
NPI:1730141763
Name:FAMILY RECOVERY HOME
Entity Type:Organization
Organization Name:FAMILY RECOVERY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:701-774-9625
Mailing Address - Street 1:126 W BROADWAY
Mailing Address - Street 2:PO BOX 1202
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-1202
Mailing Address - Country:US
Mailing Address - Phone:701-774-9625
Mailing Address - Fax:701-572-4106
Practice Address - Street 1:126 W BROADWAY
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6053
Practice Address - Country:US
Practice Address - Phone:701-774-9625
Practice Address - Fax:701-572-4106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01280003OtherB LUE CROSS