Healthcare Provider Details

I. General information

NPI: 1154343176
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: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W CENTENNIAL 84 DRIVE
NEW YORK MILLS MN
56567-0364
US

IV. Provider business mailing address

PO BOX D 20 W CENTENNIAL 84 DRIVE
NEW YORK MILLS MN
56567-0364
US

V. Phone/Fax

Practice location:
  • Phone: 218-385-1800
  • Fax: 218-385-1830
Mailing address:
  • Phone: 218-385-1800
  • Fax: 218-385-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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