Basic Information
| Provider Information | |||||||||
| NPI: | 1669998571 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY'S REGIONAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ESSENTIA HEALTH PARK RAPIDS THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | MEDICAL STAFF SERVICES-SSC | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648177 | ||||||||
| FaxNumber: | 7013648476 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 1ST ST E | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322858 | ||||||||
| FaxNumber: | 2187322876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | GOODRICH | ||||||||
| AuthorizedOfficialFirstName: | TANNER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2188475611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST MARY'S REGIONAL HEALTH CENTER | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.