Provider Demographics
NPI:1922184167
Name:DAKOTA BOYS & GIRLS RANCH ASSOCIATION
Entity Type:Organization
Organization Name:DAKOTA BOYS & GIRLS RANCH ASSOCIATION
Other - Org Name:DAKOTA BOYS RANCH FARGO RTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHONDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-858-0115
Mailing Address - Street 1:7151 15TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-858-0115
Mailing Address - Fax:
Practice Address - Street 1:6301 19TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703
Practice Address - Country:US
Practice Address - Phone:701-858-0115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10348OtherBLUE CROSS
ND50521Medicaid