Provider Demographics
NPI:1235309063
Name:304
Entity type:Organization
Organization Name:304
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:REMBOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-663-0379
Mailing Address - Street 1:201 4TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3135
Mailing Address - Country:US
Mailing Address - Phone:701-663-0379
Mailing Address - Fax:701-663-1535
Practice Address - Street 1:304 11TH ST NE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-2140
Practice Address - Country:US
Practice Address - Phone:701-663-1635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIT INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-07
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
ND320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND003200006Medicaid
ND1455894Medicaid