=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497761852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANFORD CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 W 18TH ST SUITE G01
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57104-4647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-328-1395
-----------------------------------------------------
Fax | 605-328-3998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1210 W 18TH ST SUITE G01
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57104-4647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-328-1395
-----------------------------------------------------
Fax | 605-328-3998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | STEVE GOETSCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-328-6940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------