Provider Demographics
NPI:1487728630
Name:THREE AFFILIATED TRIBES DIALYSIS UNIT
Entity type:Organization
Organization Name:THREE AFFILIATED TRIBES DIALYSIS UNIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-627-4840
Mailing Address - Street 1:9281 HIGHWAY 23
Mailing Address - Street 2:
Mailing Address - City:NEW TOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58763-9407
Mailing Address - Country:US
Mailing Address - Phone:701-627-4840
Mailing Address - Fax:
Practice Address - Street 1:9281 HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:NEW TOWN
Practice Address - State:ND
Practice Address - Zip Code:58763-9407
Practice Address - Country:US
Practice Address - Phone:701-627-4840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1083625354261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND003123Medicaid
ND003123Medicaid