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General NPI Number Information
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NPI Number | 1174662852
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Entity Type | Organization
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Legal Business Name | ALTRU FAMILY MEDICINE CENTER
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 10/16/2012
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Provider Practice Location Address
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Address Line | 1380 S COLUMBIA RD
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City | GRAND FORKS
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State | ND
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Zip | 58201-4059
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Country | US
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Telephone | 701-795-2230
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Fax |
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Provider Business Mailing Address
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Address Line | 5626 OBERLIN DR SUITE 110
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City | SAN DIEGO
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State | CA
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Zip | 92121-1705
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Country | US
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Telephone | 858-625-2990
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Fax | 858-625-2999
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | MR. KENNY HEINE
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Credential |
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Telephone | 858-625-2990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | 5809
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License Number State | ND
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