Healthcare Provider Details

I. General information

NPI: 1235170747
Provider Name (Legal Business Name): SANFORD CLINIC NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WASHINGTON AVE
DETROIT LAKES MN
56501-3905
US

IV. Provider business mailing address

1245 WASHINGTON AVE
DETROIT LAKES MN
56501-3905
US

V. Phone/Fax

Practice location:
  • Phone: 218-846-2000
  • Fax: 218-846-2114
Mailing address:
  • Phone: 218-846-2000
  • Fax: 218-846-2114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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