Provider Demographics
NPI:1912387630
Name:TRENTON INDIAN SERVICE AREA
Entity Type:Organization
Organization Name:TRENTON INDIAN SERVICE AREA
Other - Org Name:TRENTON COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-774-0461
Mailing Address - Street 1:331 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:ND
Mailing Address - Zip Code:58853-9998
Mailing Address - Country:US
Mailing Address - Phone:701-774-0461
Mailing Address - Fax:701-774-8003
Practice Address - Street 1:331 4TH AVE E
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:ND
Practice Address - Zip Code:58853-9998
Practice Address - Country:US
Practice Address - Phone:701-774-0461
Practice Address - Fax:701-774-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1312Medicaid
ND1312Medicaid