Healthcare Provider Details

I. General information

NPI: 1497804082
Provider Name (Legal Business Name): RED RIVER PLASTIC SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 CENTRAL AVE NE
EAST GRAND FORKS MN
56721-1605
US

IV. Provider business mailing address

1428 CENTRAL AVE NE
EAST GRAND FORKS MN
56721-1605
US

V. Phone/Fax

Practice location:
  • Phone: 866-773-1390
  • Fax:
Mailing address:
  • Phone: 866-773-1390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JUDSON CROW
Title or Position: OWNER
Credential: MD
Phone: 866-773-1390