Provider Demographics
NPI:1487731030
Name:KIDDER COUNTY PRIMARY HEALTHCARE CORPORATION
Entity type:Organization
Organization Name:KIDDER COUNTY PRIMARY HEALTHCARE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-475-2910
Mailing Address - Street 1:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:STEELE
Mailing Address - State:ND
Mailing Address - Zip Code:58482-0054
Mailing Address - Country:US
Mailing Address - Phone:701-475-2910
Mailing Address - Fax:701-475-2815
Practice Address - Street 1:110 W BROADWAY
Practice Address - Street 2:
Practice Address - City:STEELE
Practice Address - State:ND
Practice Address - Zip Code:58482
Practice Address - Country:US
Practice Address - Phone:701-475-2910
Practice Address - Fax:701-475-2815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6975261Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14152Medicaid
ND06935001OtherBCBS
ND5189Medicaid
DF9827OtherRR MEDICARE
ND06935001OtherBCBS
ND5189Medicaid
N712479 PART BMedicare PIN