1730863937 NPI number — CAROL GRETTUM CP, CPED

Table of content: CAROL GRETTUM CP, CPED (NPI 1730863937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730863937 NPI number — CAROL GRETTUM CP, CPED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRETTUM
Provider First Name:
CAROL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CP, CPED
Provider Gender Code:
F

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:
1730863937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 32ND AVE W APT 602
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58078-2947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-261-6601
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
FARGO VA HEALTHCARE SYSTEM
Provider Second Line Business Practice Location Address:
2101 ELM STREET N
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-239-3700
Provider Business Practice Location Address Fax Number:
701-239-3721
Provider Enumeration Date:
06/09/2023

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: 224L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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