1790791101 NPI number — SANFORD CLINIC

Table of content: (NPI 1790791101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790791101 NPI number — SANFORD CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANFORD CLINIC
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:
1790791101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1210 W 18TH ST
Provider Second Line Business Mailing Address:
SUITE G01
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57104-4647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-328-1750
Provider Business Mailing Address Fax Number:
605-328-1751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 W 18TH ST
Provider Second Line Business Practice Location Address:
SUITE G01
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57104-4647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-328-1750
Provider Business Practice Location Address Fax Number:
605-328-1751
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GEOTSCH
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
605-328-4538

Provider Taxonomy Codes

  • Taxonomy code: 207RS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 684424300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0562025 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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