Provider Demographics
NPI:1184171753
Name:DAKOTA RENAISSANCE, INC.
Entity type:Organization
Organization Name:DAKOTA RENAISSANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCHARAZARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-310-9346
Mailing Address - Street 1:101 3RD AVE
Mailing Address - Street 2:P.O. BOX 44
Mailing Address - City:PETTIBONE
Mailing Address - State:ND
Mailing Address - Zip Code:58475
Mailing Address - Country:US
Mailing Address - Phone:701-273-6688
Mailing Address - Fax:888-972-4098
Practice Address - Street 1:101 3RD AVE
Practice Address - Street 2:# 44
Practice Address - City:PETTIBONE
Practice Address - State:ND
Practice Address - Zip Code:58475
Practice Address - Country:US
Practice Address - Phone:701-273-6688
Practice Address - Fax:888-972-4098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12015261QR1100X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch