=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255348280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANFORD CLINIC NORTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 WILEY AVENUE SOUTH
-----------------------------------------------------
City | LIDGERWOOD
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58053-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-538-4189
-----------------------------------------------------
Fax | 701-538-4319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 FOURTH STREET S
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58122-0605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-234-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | MARTHA K LECLERC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-234-6248
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------