Provider Demographics
NPI:1720293301
Name:CHARLES HALL YOUTH SERVICES INC.
Entity type:Organization
Organization Name:CHARLES HALL YOUTH SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KLOPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-255-2773
Mailing Address - Street 1:513 E BISMARCK EXPY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6577
Mailing Address - Country:US
Mailing Address - Phone:701-255-2773
Mailing Address - Fax:701-255-6261
Practice Address - Street 1:513 E BISMARCK EXPY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6577
Practice Address - Country:US
Practice Address - Phone:701-255-2773
Practice Address - Fax:701-255-6261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27505OtherLAVONNA FUCHS - BCBS PIN
ND27506OtherKATHRYN KRUKENBERG TRIWES
ND19167Medicaid
ND27506OtherKATHRYN KRUKENBERG BCBS
ND27507OtherAMY FAST TRIWEST PIN
ND27505OtherTRIWEST PIN
ND27507OtherAMY FAST BCBS PIN
ND74005Medicaid
ND74006Medicaid
ND74003Medicaid
ND50602Medicaid
ND74004Medicaid