Healthcare Provider Details

I. General information

NPI: 1003850231
Provider Name (Legal Business Name): TERRY A CLINKENBEARD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGHWAY 2 W
DEVILS LAKE ND
58301-3532
US

IV. Provider business mailing address

PO BOX 650
DEVILS LAKE ND
58301-0650
US

V. Phone/Fax

Practice location:
  • Phone: 701-665-2200
  • Fax: 701-665-2300
Mailing address:
  • Phone: 701-665-2200
  • Fax: 701-665-2300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5449
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: