=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245284314
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ARCHULETA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2006
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 SUNSET DRIVE NW
-----------------------------------------------------
City | MANDAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-667-4600
-----------------------------------------------------
Fax | 701-530-3780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 997
-----------------------------------------------------
City | BISMARCK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58502-0997
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-667-4600
-----------------------------------------------------
Fax | 701-530-3780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 9721
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 9721
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------