Provider Demographics
NPI: | 1922529932 |
---|---|
Name: | NORTHEAST HUMAN SERVICE CENTER |
Entity Type: | Organization |
Organization Name: | NORTHEAST HUMAN SERVICE CENTER |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | REGIONAL DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | RANDALL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SLAVENS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 701-795-3010 |
Mailing Address - Street 1: | 151 S 4TH ST STE 401 |
Mailing Address - Street 2: | |
Mailing Address - City: | GRAND FORKS |
Mailing Address - State: | ND |
Mailing Address - Zip Code: | 58201-4715 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 701-795-3000 |
Mailing Address - Fax: | 701-795-3020 |
Practice Address - Street 1: | 151 S 4TH ST STE 401 |
Practice Address - Street 2: | |
Practice Address - City: | GRAND FORKS |
Practice Address - State: | ND |
Practice Address - Zip Code: | 58201-4715 |
Practice Address - Country: | US |
Practice Address - Phone: | 701-795-3000 |
Practice Address - Fax: | 701-795-3020 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-06-29 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ND | ND249517 | Medicaid |