Provider Demographics
NPI:1639750755
Name:SPACEK, CAROLINE ANN (CFO)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ANN
Last Name:SPACEK
Suffix:
Gender:F
Credentials:CFO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3362 35TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8835
Mailing Address - Country:US
Mailing Address - Phone:701-364-6240
Mailing Address - Fax:
Practice Address - Street 1:3362 35TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8835
Practice Address - Country:US
Practice Address - Phone:701-634-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDCFO05278225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter