1457302176 NPI number — DAKOTA CLINIC, LTD.

Table of content: (NPI 1457302176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457302176 NPI number — DAKOTA CLINIC, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAKOTA CLINIC, LTD.
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:
6
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:
1457302176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 11TH ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAHPETON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58075-4655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-642-2000
Provider Business Mailing Address Fax Number:
701-671-4106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 MAIN AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANKINSON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58041-4108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-242-7118
Provider Business Practice Location Address Fax Number:
701-242-7028
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SOLBERG
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
ADMINISTRATOR-AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
701-364-3405

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10174 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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