Provider Demographics
NPI:1164642377
Name:POITRA, SANDRA M (LRD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:POITRA
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-0160
Mailing Address - Country:US
Mailing Address - Phone:701-477-8443
Mailing Address - Fax:701-477-8410
Practice Address - Street 1:1 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316
Practice Address - Country:US
Practice Address - Phone:701-477-6111
Practice Address - Fax:701-477-8410
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND835722133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered