Provider Demographics
NPI:1902803802
Name:ST. ANDREW'S BOTTINEAU CLINIC, LLC
Entity Type:Organization
Organization Name:ST. ANDREW'S BOTTINEAU CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:ATKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-228-9300
Mailing Address - Street 1:314 OHMER ST
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-1045
Mailing Address - Country:US
Mailing Address - Phone:701-228-9400
Mailing Address - Fax:701-228-3245
Practice Address - Street 1:314 OHMER ST
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318-1045
Practice Address - Country:US
Practice Address - Phone:701-228-9400
Practice Address - Fax:701-228-3245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND353851261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND05165Medicaid
ND10818Medicaid
ND05165Medicaid
ND10818Medicaid