Provider Demographics
NPI:1093997017
Name:SANFORD CLINIC
Entity Type:Organization
Organization Name:SANFORD CLINIC
Other - Org Name:SANFORD USD 34TH & KIWANIS FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-328-8384
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 S KIWANIS AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4252
Practice Address - Country:US
Practice Address - Phone:605-328-0020
Practice Address - Fax:605-328-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1308710041Medicare NSC
SDS8255Medicare PIN
SDCH8874Medicare PIN