Provider Demographics
NPI:1710909304
Name:SANFORD CLINIC NORTH
Entity Type:Organization
Organization Name:SANFORD CLINIC NORTH
Other - Org Name:SANFORD HAWLEY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:K
Authorized Official - Last Name:LECLERC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-234-6248
Mailing Address - Street 1:720 4TH ST N
Mailing Address - Street 2:PO BOX 2010
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0605
Mailing Address - Country:US
Mailing Address - Phone:218-483-3564
Mailing Address - Fax:218-483-3567
Practice Address - Street 1:1412 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:MN
Practice Address - Zip Code:56549-0746
Practice Address - Country:US
Practice Address - Phone:218-483-3564
Practice Address - Fax:218-483-3567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN428716900Medicaid
MNC02387Medicare PIN
MN428716900Medicaid