Provider Demographics
NPI:1063613438
Name:COUNTY OF DICKEY
Entity type:Organization
Organization Name:COUNTY OF DICKEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-349-4348
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:ND
Mailing Address - Zip Code:58436-0238
Mailing Address - Country:US
Mailing Address - Phone:701-349-4348
Mailing Address - Fax:701-349-3277
Practice Address - Street 1:205 15TH STREET NORTH
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:ND
Practice Address - Zip Code:58436
Practice Address - Country:US
Practice Address - Phone:701-349-4348
Practice Address - Fax:701-349-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDAN7413254251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51756Medicaid
ND51756Medicaid