Provider Demographics
NPI:1104490622
Name:SPECTRA HEALTH
Entity type:Organization
Organization Name:SPECTRA HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CPA
Authorized Official - Phone:701-757-2100
Mailing Address - Street 1:212 S 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4781
Mailing Address - Country:US
Mailing Address - Phone:701-757-2100
Mailing Address - Fax:
Practice Address - Street 1:607 TOWNER AVE
Practice Address - Street 2:
Practice Address - City:LARIMORE
Practice Address - State:ND
Practice Address - Zip Code:58251-4501
Practice Address - Country:US
Practice Address - Phone:701-343-6418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1461963Medicaid
ND1461598Medicaid