Provider Demographics
NPI:1942398508
Name:WEST RIVER HEALTH SERVICES
Entity Type:Organization
Organization Name:WEST RIVER HEALTH SERVICES
Other - Org Name:MOTT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-567-6184
Mailing Address - Street 1:1000 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:HETTINGER
Mailing Address - State:ND
Mailing Address - Zip Code:58639-7530
Mailing Address - Country:US
Mailing Address - Phone:701-567-4561
Mailing Address - Fax:701-567-6369
Practice Address - Street 1:420 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:MOTT
Practice Address - State:ND
Practice Address - Zip Code:58646
Practice Address - Country:US
Practice Address - Phone:701-824-2391
Practice Address - Fax:701-824-2846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND005014Medicaid
NE=========13Medicaid
ND353980Medicare Oscar/Certification