Provider Demographics
NPI:1780690305
Name:SANFORD CLINIC NORTH
Entity Type:Organization
Organization Name:SANFORD CLINIC NORTH
Other - Org Name:SANFORD HEALTH GWINNER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARTH
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 FOURTH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0605
Mailing Address - Country:US
Mailing Address - Phone:701-234-2000
Mailing Address - Fax:
Practice Address - Street 1:69 HIGHWAY 13 W
Practice Address - Street 2:
Practice Address - City:GWINNER
Practice Address - State:ND
Practice Address - Zip Code:58040-4127
Practice Address - Country:US
Practice Address - Phone:701-678-2263
Practice Address - Fax:701-678-2063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12857Medicaid
NDCF8850OtherRAILROAD MEDICARE
ND1330001OtherBLUE SHIELD
ND5130Medicaid
ND353846Medicare Oscar/Certification
NDN70957Medicare PIN
NDCF8850Medicare PIN
ND5130Medicaid