Provider Demographics
NPI:1811521552
Name:WHITE SPRUCE MEDICAL, LLC
Entity type:Organization
Organization Name:WHITE SPRUCE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-452-3600
Mailing Address - Street 1:1275 SADLER WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3175
Mailing Address - Country:US
Mailing Address - Phone:907-452-3600
Mailing Address - Fax:907-452-3695
Practice Address - Street 1:1275 SADLER WAY STE 100
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3175
Practice Address - Country:US
Practice Address - Phone:907-452-3600
Practice Address - Fax:907-452-3695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Single Specialty