Healthcare Provider Details

I. General information

NPI: 1841953379
Provider Name (Legal Business Name): SPECTRA HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S 4TH ST STE 301
GRAND FORKS ND
58201-4776
US

IV. Provider business mailing address

212 S 4TH ST
GRAND FORKS ND
58201-4777
US

V. Phone/Fax

Practice location:
  • Phone: 701-757-2100
  • Fax:
Mailing address:
  • Phone: 701-757-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: TIFFANY SCHMIDT
Title or Position: CFO
Credential:
Phone: 701-757-2100