Healthcare Provider Details

I. General information

NPI: 1407878424
Provider Name (Legal Business Name): SANFORD CLINIC NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604 BEMIDJI AVE N
BEMIDJI MN
56601-4333
US

IV. Provider business mailing address

3604 BEMIDJI AVE N
BEMIDJI MN
56601-4333
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5111
  • Fax: 218-333-5458
Mailing address:
  • Phone: 218-333-5111
  • Fax: 218-333-5458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTHA K LECLERC
Title or Position: VP
Credential:
Phone: 701-234-6248