1720156664 NPI number — CENTRAL DAKOTA FAMILY PHYSICIANS, PC

Table of content: ETHAN WOLFF PT, DPT (NPI 1942966296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720156664 NPI number — CENTRAL DAKOTA FAMILY PHYSICIANS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL DAKOTA FAMILY PHYSICIANS, PC
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:
1720156664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
922 LINCOLN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARVEY
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58341-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-324-4856
Provider Business Mailing Address Fax Number:
701-324-4858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
922 LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARVEY
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58341-1524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-324-4856
Provider Business Practice Location Address Fax Number:
701-324-4858
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NYHUS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
701-324-4856

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: 10310 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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