Healthcare Provider Details

I. General information

NPI: 1275898678
Provider Name (Legal Business Name): PRACS INSTITUTE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 AMBER VALLEY PKWY S
FARGO ND
58104-8623
US

IV. Provider business mailing address

4801 AMBER VALLEY PKWY S
FARGO ND
58104-8623
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-4750
  • Fax:
Mailing address:
  • Phone: 701-239-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: KATHERINE CLONINGER
Title or Position: DIRECTOR, MARKETING
Credential:
Phone: 843-478-0150