Healthcare Provider Details

I. General information

NPI: 1972711521
Provider Name (Legal Business Name): LORI HEFTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 8TH AVE NE
HAZEN ND
58545-4637
US

IV. Provider business mailing address

510 8TH AVE NE
HAZEN ND
58545-4637
US

V. Phone/Fax

Practice location:
  • Phone: 701-748-2225
  • Fax: 701-748-5757
Mailing address:
  • Phone: 701-748-2225
  • Fax: 701-748-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number793
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: