Provider Demographics
NPI:1154343176
Name:SANFORD CLINIC NORTH
Entity type:Organization
Organization Name:SANFORD CLINIC NORTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:K
Authorized Official - Last Name:LECLERC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-234-6248
Mailing Address - Street 1:PO BOX D
Mailing Address - Street 2:20 W CENTENNIAL 84 DRIVE
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:MN
Mailing Address - Zip Code:56567-0364
Mailing Address - Country:US
Mailing Address - Phone:218-385-1800
Mailing Address - Fax:218-385-1830
Practice Address - Street 1:20 W CENTENNIAL 84 DRIVE
Practice Address - Street 2:
Practice Address - City:NEW YORK MILLS
Practice Address - State:MN
Practice Address - Zip Code:56567-0364
Practice Address - Country:US
Practice Address - Phone:218-385-1800
Practice Address - Fax:218-385-1830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN463217600Medicaid
MN463217600Medicaid