Provider Demographics
NPI:1699548214
Name:PROVIDENCE HOUSE MINOT LLC
Entity type:Organization
Organization Name:PROVIDENCE HOUSE MINOT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-828-3300
Mailing Address - Street 1:PO BOX 1286
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-1286
Mailing Address - Country:US
Mailing Address - Phone:701-838-3300
Mailing Address - Fax:
Practice Address - Street 1:415 MAIN ST S
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4414
Practice Address - Country:US
Practice Address - Phone:701-838-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit