Healthcare Provider Details

I. General information

NPI: 1245309780
Provider Name (Legal Business Name): COMPREHENSIVE PEDIATRIC CARE, P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 W DAKOTA PKWY STE 2A
WILLISTON ND
58801-3854
US

IV. Provider business mailing address

PO BOX 696
WILLISTON ND
58802-0696
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-7732
  • Fax: 701-572-7997
Mailing address:
  • Phone: 701-572-7732
  • Fax: 701-572-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GLEN W FINLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 701-572-7732