1548323314 NPI number — SPIRIT LAKE HEALTH CENTER

Table of content: (NPI 1548323314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548323314 NPI number — SPIRIT LAKE HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPIRIT LAKE HEALTH CENTER
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:
1548323314
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:
PO BOX 309
Provider Second Line Business Mailing Address:
3883 74TH AVE NE
Provider Business Mailing Address City Name:
FORT TOTTEN
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58335-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3883 74TH AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT TOTTEN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-766-1612
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTELL
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
701-766-1600

Provider Taxonomy Codes

  • Taxonomy code: 261QP0904X , with the licence number:  AU46983207 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01056 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3503693 . This is a "NCPDP" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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