Provider Demographics
NPI:1790080356
Name:NORTH DAKOTA YOUTH CORRECTIONAL CENTER
Entity Type:Organization
Organization Name:NORTH DAKOTA YOUTH CORRECTIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-667-1401
Mailing Address - Street 1:701 16TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-5800
Mailing Address - Country:US
Mailing Address - Phone:701-667-1400
Mailing Address - Fax:701-667-1414
Practice Address - Street 1:701 16TH AVE SW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-5800
Practice Address - Country:US
Practice Address - Phone:701-667-1400
Practice Address - Fax:701-667-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center