=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255353934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANFORD CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1305 W 18TH ST
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57105-0401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-328-4539
-----------------------------------------------------
Fax | 605-328-4531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1305 W 18TH ST
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57105-0401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-328-4539
-----------------------------------------------------
Fax | 605-328-4531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | STEVE W GOETSCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-328-6940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 246Q00000X
-----------------------------------------------------
Taxonomy Name | Pathology Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------