Healthcare Provider Details

I. General information

NPI: 1932559564
Provider Name (Legal Business Name): MOLLY JEAN SOEBY MT, SC (ASCP), MPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 S 4TH ST STE 302
GRAND FORKS ND
58201-4715
US

IV. Provider business mailing address

718 OAK ST
GRAND FORKS ND
58201-4460
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-8229
  • Fax:
Mailing address:
  • Phone: 218-230-0070
  • Fax: 800-958-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number90-0456-I
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: