Provider Demographics
NPI:1972535433
Name:SPIRIT LAKE HEALTH CENTER
Entity type:Organization
Organization Name:SPIRIT LAKE HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACTING CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-766-1600
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:3883 74TH AVE. NE
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0309
Mailing Address - Country:US
Mailing Address - Phone:701-766-7600
Mailing Address - Fax:701-766-1630
Practice Address - Street 1:3883 74TH AVE. NE
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335-0309
Practice Address - Country:US
Practice Address - Phone:701-766-7600
Practice Address - Fax:701-766-1630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
5764240001Medicare NSC
NDHSZ056Medicare ID - Type Unspecified