Basic Information
| Provider Information | |||||||||
| NPI: | 1558451757 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAKOTA CLINIC, LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAKOTA CLINIC, LTD. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SOLBERG | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR-AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7013643405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TF0000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Family | 111N00000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 133NN1002X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 152W00000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 163W00000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207Q00000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 213E00000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 225100000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 2471M2300X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Mammography | 363A00000X | ND | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 10046 | 05 | ND | MEDICAID |