Healthcare Provider Details

I. General information

NPI: 1114142569
Provider Name (Legal Business Name): CLAY COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 11TH ST N STE 303
MOORHEAD MN
56560-2083
US

IV. Provider business mailing address

715 11TH ST N STE 303
MOORHEAD MN
56560-2083
US

V. Phone/Fax

Practice location:
  • Phone: 218-299-7301
  • Fax: 218-299-5795
Mailing address:
  • Phone: 218-299-7301
  • Fax: 218-299-5195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: LORI J JOHNSON
Title or Position: CLAY COUNTY AUDITOR
Credential:
Phone: 218-299-5262