MEDICARE: SPIRIT LAKE HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP0904X	Federal Public Health Clinic/Center

General Provider Information

NPI Number	:	1972535433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPIRIT LAKE HEALTH CENTER

Provider Business Mailing Address
First Line	:	PO BOX 309
Second Line	:	3883 74TH AVE. NE
City	:	FORT TOTTEN
State	:	ND
Zip	:	58335-0309
Country	:	US
Telephone Number	:	701-766-7600
Fax Number	:	701-766-1630

Provider Business Practice Location Address
First Line	:	3883 74TH AVE. NE
Second Line	:
City	:	FORT TOTTEN
State	:	ND
Zip	:	58335-0309
Country	:	US
Telephone Number	:	701-766-7600
Fax Number	:	701-766-1630

Authorized Official
Title or Position	:	ACTING CEO
Name	:	MR. DARREN C MARTELL
Credential	:
Telephone Number	:	701-766-1600

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	02/23/2009

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Directions to “SPIRIT LAKE HEALTH CENTER ” Practice Location

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