1346338100 NPI number — BECKY J SORENSON DPT

Table of content: BECKY J SORENSON DPT (NPI 1346338100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346338100 NPI number — BECKY J SORENSON DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SORENSON
Provider First Name:
BECKY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FUHRER
Provider Other First Name:
BECKY
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346338100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6001
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:
58108-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-253-5300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2430 20TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58401-6201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-253-5300
Provider Business Practice Location Address Fax Number:
701-253-5402
Provider Enumeration Date:
10/10/2006

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:  1308 , 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: 54637 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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