Basic Information
Provider Information | |||||||||
NPI: | 1760680300 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PONEMAH CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | HWY 1 | ||||||||
Address2: | BOX 497 | ||||||||
City: | RED LAKE | ||||||||
State: | MN | ||||||||
PostalCode: | 56671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2186793912 | ||||||||
FaxNumber: | 2186790181 | ||||||||
Practice Location | |||||||||
Address1: | HWY 1 | ||||||||
Address2: | BOX 497 | ||||||||
City: | RED LAKE | ||||||||
State: | MN | ||||||||
PostalCode: | 56671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2186793912 | ||||||||
FaxNumber: | 2186790181 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2007 | ||||||||
LastUpdateDate: | 08/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DUDLEY | ||||||||
AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL STAFF COOR. | ||||||||
AuthorizedOfficialTelephone: | 2186793912 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.