Basic Information
| Provider Information | |||||||||
| NPI: | 1780690305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD CLINIC NORTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANFORD HEALTH GWINNER CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 FOURTH STREET NORTH | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 69 HIGHWAY 13 W | ||||||||
| Address2: | |||||||||
| City: | GWINNER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580404127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016782263 | ||||||||
| FaxNumber: | 7016782063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | LECLERC | ||||||||
| AuthorizedOfficialFirstName: | MARTH | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 7012346248 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 12857 | 05 | ND | MEDICAID | CF8850 | 01 | ND | RAILROAD MEDICARE | OTHER | 1330001 | 01 | ND | BLUE SHIELD | OTHER | 5130 | 05 | ND | MEDICAID |