Healthcare Provider Details

I. General information

NPI: 1942626395
Provider Name (Legal Business Name): SANFORD BISMARCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E MAIN AVE STE 301
BISMARCK ND
58501-3857
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-323-5626
  • Fax:
Mailing address:
  • Phone: 605-333-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number40241598123
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CRAIG LAMBRECHT
Title or Position: CEO
Credential: M.D.
Phone: 701-323-6000