Provider Demographics
NPI:1033180153
Name:VALLEY BONE AND JOINT CLINIC PC
Entity Type:Organization
Organization Name:VALLEY BONE AND JOINT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:LORAE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-738-4250
Mailing Address - Street 1:3035 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4018
Mailing Address - Country:US
Mailing Address - Phone:701-746-7521
Mailing Address - Fax:701-795-2553
Practice Address - Street 1:3035 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4018
Practice Address - Country:US
Practice Address - Phone:701-746-7521
Practice Address - Fax:701-795-2553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A001OtherTRICARE
ND1461055Medicaid
MN59D70BROtherBCBS
MN201998100Medicaid
ND00112001OtherBCBS
CG0878OtherRR MEDICARE
MNC03004Medicare PIN
CG0878OtherRR MEDICARE
ND1461055Medicaid
MN201998100Medicaid