Healthcare Provider Details

I. General information

NPI: 1780788380
Provider Name (Legal Business Name): TRENTON INDIAN SERVICE AREA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 4TH AVE E
TRENTON ND
58853-9998
US

IV. Provider business mailing address

331 4TH AVE E
TRENTON ND
58853-9998
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-0461
  • Fax: 701-774-8003
Mailing address:
  • Phone: 701-774-0461
  • Fax: 701-774-8003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. WALT MORAN
Title or Position: CHAIRMAN
Credential:
Phone: 701-774-0461