Provider Demographics
NPI:1992462774
Name:SHAREHOUSE GRAND FORKS
Entity type:Organization
Organization Name:SHAREHOUSE GRAND FORKS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAEN
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW,LCAC,LADCMBA
Authorized Official - Phone:701-532-4345
Mailing Address - Street 1:1122 N 43RD ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-1930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 N 43RD ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-1930
Practice Address - Country:US
Practice Address - Phone:701-373-8661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAREHOUSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-29
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder