Provider Demographics
NPI:1730248238
Name:MINOT VOC ADJ WORKSHOP
Entity type:Organization
Organization Name:MINOT VOC ADJ WORKSHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:701-852-1014
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-1030
Mailing Address - Country:US
Mailing Address - Phone:701-852-1014
Mailing Address - Fax:701-852-1139
Practice Address - Street 1:605 27TH ST SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-5169
Practice Address - Country:US
Practice Address - Phone:701-852-1014
Practice Address - Fax:701-852-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30820Medicaid