Provider Demographics
NPI:1457189037
Name:RESILIENT HEALTH AND TRAUMA CENTER PLLC
Entity type:Organization
Organization Name:RESILIENT HEALTH AND TRAUMA CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-580-4091
Mailing Address - Street 1:13351 YELLOWSTONE MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-9110
Mailing Address - Country:US
Mailing Address - Phone:208-403-2892
Mailing Address - Fax:
Practice Address - Street 1:125 MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6030
Practice Address - Country:US
Practice Address - Phone:208-403-2892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)