Healthcare Provider Details

I. General information

NPI: 1710922059
Provider Name (Legal Business Name): MICHAEL CARR LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7965 COUNTY 1
DEVILS LAKE ND
58301-8914
US

IV. Provider business mailing address

7965 COUNTY 1
DEVILS LAKE ND
58301-8914
US

V. Phone/Fax

Practice location:
  • Phone: 701-253-6326
  • Fax:
Mailing address:
  • Phone: 701-253-6326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1457
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier019716
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBCBS PIN
# 2
Identifier54521
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: