Healthcare Provider Details

I. General information

NPI: 1548323314
Provider Name (Legal Business Name): SPIRIT LAKE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 74TH AVE NE
FT TOTTEN ND
58301
US

IV. Provider business mailing address

PO BOX 309 3883 74TH AVE NE
FORT TOTTEN ND
58335-0309
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-1612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License NumberAU46983207
License Number State

VIII. Authorized Official

Name: MR. DARREN MARTELL
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 701-766-1600