Basic Information
| Provider Information | |||||||||
| NPI: | 1699927897 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHLAND PACE PROGRAM | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 201 N 24TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017513050 | ||||||||
| FaxNumber: | 7017513053 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 N 24TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017513050 | ||||||||
| FaxNumber: | 7017513053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | WETZEL | ||||||||
| AuthorizedOfficialFirstName: | RODGER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7017513050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X | H7195 | Y | Agencies | PACE Provider Organization |
No ID Information.