Provider Demographics
NPI:1255317905
Name:SPECTRA HEALTH
Entity Type:Organization
Organization Name:SPECTRA HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-2812
Mailing Address - Street 1:212 S 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4781
Mailing Address - Country:US
Mailing Address - Phone:701-757-2100
Mailing Address - Fax:701-757-0305
Practice Address - Street 1:607 TOWNER AVE
Practice Address - Street 2:
Practice Address - City:LARIMORE
Practice Address - State:ND
Practice Address - Zip Code:58251
Practice Address - Country:US
Practice Address - Phone:701-343-6418
Practice Address - Fax:701-343-2937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND05908Medicaid
ND05908Medicaid