Healthcare Provider Details

I. General information

NPI: 1033180153
Provider Name (Legal Business Name): VALLEY BONE AND JOINT CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 DEMERS AVE
GRAND FORKS ND
58201-4018
US

IV. Provider business mailing address

3035 DEMERS AVE
GRAND FORKS ND
58201-4018
US

V. Phone/Fax

Practice location:
  • Phone: 701-746-7521
  • Fax: 701-795-2553
Mailing address:
  • Phone: 701-746-7521
  • Fax: 701-795-2553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: LORAE BENSON
Title or Position: MGR
Credential:
Phone: 701-738-4250