1922123108 NPI number — SANFORD CLINIC

Table of content: (NPI 1922123108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922123108 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:
1922123108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-312-7605
Provider Business Mailing Address Fax Number:
605-312-7611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 S BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-882-1852
Provider Business Practice Location Address Fax Number:
605-886-9799
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MORRISON
Authorized Official First Name:
TONY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
VICE PRESIDENT, REVENUE CYCLE
Authorized Official Telephone Number:
605-328-8380

Provider Taxonomy Codes

  • Taxonomy code: 261QF0050X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5100130 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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