Provider Demographics
NPI:1134303795
Name:SPIRIT LAKE HEALTH CENTER
Entity Type:Organization
Organization Name:SPIRIT LAKE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL INSTRUMENT TECHNOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:COLETTTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BYRUM
Authorized Official - Suffix:
Authorized Official - Credentials:BSRT(R)(M)
Authorized Official - Phone:701-766-1629
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0309
Mailing Address - Country:US
Mailing Address - Phone:701-766-1600
Mailing Address - Fax:
Practice Address - Street 1:3883 74TH AVE NE
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335-0309
Practice Address - Country:US
Practice Address - Phone:701-766-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND001061Medicaid
NDHSZ056Medicare PIN