Provider Demographics
NPI:1366468449
Name:SANFORD CLINIC
Entity Type:Organization
Organization Name:SANFORD CLINIC
Other - Org Name:SANFORD EYE CENTER & OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:W
Authorized Official - Last Name:GOETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-328-6940
Mailing Address - Street 1:1621 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1743
Mailing Address - Country:US
Mailing Address - Phone:605-328-9200
Mailing Address - Fax:605-328-9201
Practice Address - Street 1:1621 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1743
Practice Address - Country:US
Practice Address - Phone:605-328-9200
Practice Address - Fax:605-328-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN281988100Medicaid
IA0537886Medicaid
IA0537886Medicaid
SDCH8874Medicare PIN
SD1308710003Medicare NSC