1730509084 NPI number — LACEY RUSTAD LSW

Table of content: LACEY RUSTAD LSW (NPI 1730509084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730509084 NPI number — LACEY RUSTAD LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSTAD
Provider First Name:
LACEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMPSON
Provider Other First Name:
LACEY
Provider Other Middle Name:
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:
1730509084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 WEST BROADWAY
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-774-6300
Provider Business Mailing Address Fax Number:
701-572-9794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 WEST BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-774-6300
Provider Business Practice Location Address Fax Number:
701-572-9794
Provider Enumeration Date:
04/24/2014

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: 171M00000X , with the licence number:  4689 , 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: 50763 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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