Healthcare Provider Details

I. General information

NPI: 1831312750
Provider Name (Legal Business Name): RED RIVER FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN AVE SUITE 200
FARGO ND
58103-1930
US

IV. Provider business mailing address

300 MAIN AVE SUITE 200
FARGO ND
58103-1930
US

V. Phone/Fax

Practice location:
  • Phone: 701-499-4340
  • Fax: 701-499-4341
Mailing address:
  • Phone: 701-499-4340
  • Fax: 701-499-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7807
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR28446
License Number StateND

VIII. Authorized Official

Name: SHANTELL MARIE TWOBEARS
Title or Position: PRESIDENT
Credential: MD
Phone: 701-499-4340