Healthcare Provider Details

I. General information

NPI: 1053594093
Provider Name (Legal Business Name): DIANNE ALETHA GOEBEL RT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 74TH AVENUE NORTH EAST
FT TOTTEN ND
58335
US

IV. Provider business mailing address

3883 74TH AVENUE NORTH EAST
FORT TOTTEN ND
58335-0309
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-1629
  • Fax:
Mailing address:
  • Phone: 701-766-1629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number081694
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: