Provider Demographics
NPI:1548050461
Name:DICKINSON COUNTRYHOUSE LLC
Entity type:Organization
Organization Name:DICKINSON COUNTRYHOUSE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP ASSET MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:531-800-3364
Mailing Address - Street 1:17110 MARCY ST STE LL01
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-3119
Mailing Address - Country:US
Mailing Address - Phone:531-800-3364
Mailing Address - Fax:531-800-3364
Practice Address - Street 1:628 24TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2731
Practice Address - Country:US
Practice Address - Phone:701-847-0842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-12
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No253Z00000XAgenciesIn Home Supportive Care