Provider Demographics
NPI:1346305190
Name:BURCKHARD CLINIC, P. C.
Entity Type:Organization
Organization Name:BURCKHARD CLINIC, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:V
Authorized Official - Last Name:BURCKHARD
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:701-852-5876
Mailing Address - Street 1:315 MAIN ST S STE 315
Mailing Address - Street 2:STE. 315
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3956
Mailing Address - Country:US
Mailing Address - Phone:701-852-5876
Mailing Address - Fax:701-852-5883
Practice Address - Street 1:315 MAIN ST S STE 315
Practice Address - Street 2:STE. 315
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3956
Practice Address - Country:US
Practice Address - Phone:701-852-5876
Practice Address - Fax:701-852-5883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND120261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11482Medicaid