Provider Demographics
NPI:1093766974
Name:DAKOTA CLINIC, LTD.
Entity Type:Organization
Organization Name:DAKOTA CLINIC, LTD.
Other - Org Name:DAKOTA CLINIC, LTD. - LISBON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR-AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SOLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-364-3405
Mailing Address - Street 1:401 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-4247
Mailing Address - Country:US
Mailing Address - Phone:701-253-5300
Mailing Address - Fax:701-253-5402
Practice Address - Street 1:819 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4244
Practice Address - Country:US
Practice Address - Phone:701-683-4134
Practice Address - Fax:701-683-4094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10894Medicaid
ND6211Medicare ID - Type UnspecifiedMEDICARE GROUP #