1114028503 NPI number — MED-PLUS HEALTH CARE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114028503 NPI number — MED-PLUS HEALTH CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED-PLUS HEALTH CARE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114028503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 SUNSET DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXBOW
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58047-5012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-588-4195
Provider Business Mailing Address Fax Number:
218-588-4196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 HIGHWAY 75 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-2407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-8544
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHOGREN
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
LESLIE
Authorized Official Title or Position:
OWNER, CHIROPRACTOR
Authorized Official Telephone Number:
218-233-8544

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1896 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225100000X , with the licence number: 6503 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11401 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com