=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265457964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANFORD CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 E 2ND ST
-----------------------------------------------------
City | IDA GROVE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51445-1666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-364-7341
-----------------------------------------------------
Fax | 712-364-7241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5074
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57117-5074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-328-6585
-----------------------------------------------------
Fax | 605-328-6512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, REVENUE CYCLE
-----------------------------------------------------
Name | TONY LEE MORRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-328-8380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------