Basic Information
Provider Information | |||||||||
NPI: | 1649226713 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST CENTRAL HUMAN SERVICE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1237 W DIVIDE AVE | ||||||||
Address2: | STE 5 | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 58501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013288888 | ||||||||
FaxNumber: | 7013288900 | ||||||||
Practice Location | |||||||||
Address1: | 1237 W DIVIDE AVE | ||||||||
Address2: | STE 5 | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 58501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013288888 | ||||||||
FaxNumber: | 7013288900 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2006 | ||||||||
LastUpdateDate: | 12/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AUKLAND | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT CFO - DHS | ||||||||
AuthorizedOfficialTelephone: | 7013284924 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X |   | ND | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X |   | ND | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QR0405X | 1018 | ND | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X |   | ND | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 241001 | 01 | ND | BCBS OF ND GROUP ID | OTHER | CN2142 | 01 | ND | RR MEDICARE GROUP ID | OTHER | 0004559496 | 01 |   | AETNA GROUP ID | OTHER | 054522 | 05 | ND |   | MEDICAID |