1518287101 NPI number — SYVRUD CHIROPRACTIC CLINIC PC

Table of content: (NPI 1518287101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518287101 NPI number — SYVRUD CHIROPRACTIC CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYVRUD CHIROPRACTIC CLINIC PC
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:
1518287101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 25TH ST S STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-8724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-237-5150
Provider Business Mailing Address Fax Number:
701-237-5150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 25TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-8724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-237-5150
Provider Business Practice Location Address Fax Number:
701-237-5150
Provider Enumeration Date:
06/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LARSON
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
701-237-5150

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  497 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 26293 . This is a "BLUE CROSS BLUE SHIELD OF ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 340115 . This is a "OPTUM HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16342 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 63140SY . This is a "BLUE CROSS BLUE SHIELD OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 653528300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 350053619 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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