Healthcare Provider Details

I. General information

NPI: 1548540842
Provider Name (Legal Business Name): SANFORD MEDICAL CENTER FARGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

IV. Provider business mailing address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-2020
  • Fax:
Mailing address:
  • Phone: 218-333-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MARTHA LECLERC
Title or Position: VICE PRESIDENT
Credential:
Phone: 701-234-6248