Healthcare Provider Details

I. General information

NPI: 1679196000
Provider Name (Legal Business Name): SCHEELS ALL SPORTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 45TH ST S
FARGO ND
58103-3255
US

IV. Provider business mailing address

4550 15TH AVE S
FARGO ND
58103-8959
US

V. Phone/Fax

Practice location:
  • Phone: 701-298-2918
  • Fax: 701-298-0706
Mailing address:
  • Phone: 701-298-2918
  • Fax: 701-298-0706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
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: JASON MACK
Title or Position: STORE LEADER
Credential:
Phone: 701-298-2918