=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346305190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURCKHARD CLINIC, P. C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2006
-----------------------------------------------------
Last Update Date | 11/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 MAIN ST S STE 315 STE. 315
-----------------------------------------------------
City | MINOT
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58701-3956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-852-5876
-----------------------------------------------------
Fax | 701-852-5883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 MAIN ST S STE 315 STE. 315
-----------------------------------------------------
City | MINOT
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58701-3956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-852-5876
-----------------------------------------------------
Fax | 701-852-5883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. MIKE V. BURCKHARD
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 701-852-5876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 120
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------