Provider Demographics
NPI:1154405983
Name:PRAIRIE LEARNING CENTER
Entity type:Organization
Organization Name:PRAIRIE LEARNING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-597-3419
Mailing Address - Street 1:7785 SAINT GERTRUDE AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:ND
Mailing Address - Zip Code:58564-4103
Mailing Address - Country:US
Mailing Address - Phone:701-597-3479
Mailing Address - Fax:
Practice Address - Street 1:7785 SAINT GERTRUDE AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:ND
Practice Address - Zip Code:58564-4103
Practice Address - Country:US
Practice Address - Phone:701-597-3479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND50605Medicaid