Basic Information
| Provider Information | |||||||||
| NPI: | 1902949845 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRINITY HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TCC-WESTERN DAKOTA LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1102 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588014233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015727711 | ||||||||
| FaxNumber: | 7015720566 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588014233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015727711 | ||||||||
| FaxNumber: | 7015720566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEEHAFER | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7018575178 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 70735 | 01 | ND | BCBS | OTHER |