1184283541 NPI number — PRACTICE PLACE, PLLC

Table of content: (NPI 1184283541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184283541 NPI number — PRACTICE PLACE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRACTICE PLACE, 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:
1184283541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2534 17TH AVE S STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-5215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-885-4551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2534 17TH AVE S STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-5215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-406-9794
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NORMANDIN
Authorized Official First Name:
SHERMAN
Authorized Official Middle Name:
MAURICE
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
701-885-4551

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1083630974 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1033210570 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124128756 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".