Provider Demographics
NPI:1205932233
Name:HEART RIVER ALCOHOL AND DRUG ABUSE SERVICES INC.
Entity type:Organization
Organization Name:HEART RIVER ALCOHOL AND DRUG ABUSE SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAC
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WIEGLENDA
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:701-483-0795
Mailing Address - Street 1:ST JOE'S PLAZA
Mailing Address - Street 2:30 7TH ST W
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4335
Mailing Address - Country:US
Mailing Address - Phone:701-483-0795
Mailing Address - Fax:701-483-0947
Practice Address - Street 1:ST JOE'S PLAZA
Practice Address - Street 2:30 7TH ST W
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4335
Practice Address - Country:US
Practice Address - Phone:701-483-0795
Practice Address - Fax:701-483-0947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1071261QM0801X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND146341Medicaid
ND11608OtherBC/BS PROVIDER #
ND1473659Medicaid
ND4626OtherBCBS
ND146339Medicaid