1316014970 NPI number — CLIFFORD W LAFRENIERE PT

Table of content: CLIFFORD W LAFRENIERE PT (NPI 1316014970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316014970 NPI number — CLIFFORD W LAFRENIERE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAFRENIERE
Provider First Name:
CLIFFORD
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1316014970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 S COLUMBIA RD
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:
58201-4039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-746-8374
Provider Business Mailing Address Fax Number:
701-780-0885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17261 STATE HWY 34
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-237-3052
Provider Business Practice Location Address Fax Number:
218-237-2311
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  316 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2505 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 54780 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2139952 . This is a "FIRST HEALTH" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 322R7LA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6404390 . This is a "MEDICA" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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