Provider Demographics
NPI:1316014970
Name:LAFRENIERE, CLIFFORD W (PT)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:W
Last Name:LAFRENIERE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4039
Mailing Address - Country:US
Mailing Address - Phone:701-746-8374
Mailing Address - Fax:701-780-0885
Practice Address - Street 1:17261 STATE HWY 34
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470
Practice Address - Country:US
Practice Address - Phone:218-237-3052
Practice Address - Fax:218-237-2311
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND316225100000X
MN2505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54780Medicaid
ND2139952OtherFIRST HEALTH
MN322R7LAOtherBCBS
ND6404390OtherMEDICA
NDP00302748Medicare ID - Type UnspecifiedRR MEDICARE
ND23431Medicare ID - Type UnspecifiedMEDICARE