Provider Demographics
NPI:1215006424
Name:DAKOTA CLINIC, LTD.
Entity Type:Organization
Organization Name:DAKOTA CLINIC, LTD.
Other - Org Name:DAKOTA CLINIC, LTD. FOSSTON
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:102 SATHER DR
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1531
Practice Address - Country:US
Practice Address - Phone:218-435-1212
Practice Address - Fax:218-435-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN163W00000X, 207Q00000X, 235Z00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN07942Medicare ID - Type UnspecifiedGROUP MEDICARE #