Provider Demographics
NPI:1427077361
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 1:253 CENTRAL AVE N
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-2941
Mailing Address - Country:US
Mailing Address - Phone:701-845-1511
Mailing Address - Fax:701-845-1513
Practice Address - Street 1:253 CENTRAL AVE N
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-2941
Practice Address - Country:US
Practice Address - Phone:701-845-1511
Practice Address - Fax:701-845-1513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640028100Medicaid
1213550037Medicare NSC