Healthcare Provider Details

I. General information

NPI: 1093015265
Provider Name (Legal Business Name): SPIRIT LAKE HEAD START
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 3RD AVE NORTH
FORT TOTTEN ND
58335
US

IV. Provider business mailing address

816 3RD AVE NORTH
FORT TOTTEN ND
58335
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-4070
  • Fax: 701-766-1357
Mailing address:
  • Phone: 701-766-4070
  • Fax: 701-766-1357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberR34550
License Number StateND

VIII. Authorized Official

Name: MARIA LANE KOCH
Title or Position: HEALTH SERVICE COORDINATOR
Credential: REGISTERED NURSE
Phone: 701-766-1370