1114343423 NPI number — SPECTRA HEALTH

Table of content: (NPI 1114343423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114343423 NPI number — SPECTRA HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRA HEALTH
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:
1114343423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 S 4TH ST STE 200
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:
58201-4781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-757-2100
Provider Business Mailing Address Fax Number:
701-757-0305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 S 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-4777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-757-2100
Provider Business Practice Location Address Fax Number:
701-757-0305
Provider Enumeration Date:
03/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SHANNON
Authorized Official First Name:
BEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
701-757-2812

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05925 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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