Provider Demographics
NPI:1285688598
Name:DAKOTA CLINIC, LTD.
Entity Type:Organization
Organization Name:DAKOTA CLINIC, LTD.
Other - Org Name:DAKOTA CLINIC, LTD. - WEST ACRES
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 1:3902 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3357
Practice Address - Country:US
Practice Address - Phone:701-364-6600
Practice Address - Fax:701-364-6628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10046Medicaid
ND10046Medicaid