Healthcare Provider Details

I. General information

NPI: 1194751594
Provider Name (Legal Business Name): SANFORD CLINIC NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 BROADWAY N
FARGO ND
58102-6704
US

IV. Provider business mailing address

2601 BROADWAY N
FARGO ND
58102-6704
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2900
  • Fax: 701-234-2996
Mailing address:
  • Phone: 701-234-2900
  • Fax: 701-234-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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