Healthcare Provider Details

I. General information

NPI: 1811162811
Provider Name (Legal Business Name): FAIRLIGHT MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 4TH ST E
WILLISTON ND
58801-5350
US

IV. Provider business mailing address

3 EAST 4TH STREET PO BOX 1148
WILLISTON ND
58802-1148
US

V. Phone/Fax

Practice location:
  • Phone: 701-577-6337
  • Fax: 701-577-4867
Mailing address:
  • Phone: 701-577-6337
  • Fax: 701-577-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number6414
License Number StateND

VIII. Authorized Official

Name: DR. LESZEK J JASZCZAK
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 701-577-6337