Healthcare Provider Details

I. General information

NPI: 1376370635
Provider Name (Legal Business Name): JUSTIN RAY PIERCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

5109 18TH ST N
MOORHEAD MN
56560-8806
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3700
  • Fax:
Mailing address:
  • Phone: 760-885-6620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberR-1375
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: