Provider Demographics
NPI:1548323314
Name:SPIRIT LAKE HEALTH CENTER
Entity type:Organization
Organization Name:SPIRIT LAKE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-766-1600
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:3883 74TH AVE NE
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3883 74TH AVE NE
Practice Address - Street 2:
Practice Address - City:FT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58301
Practice Address - Country:US
Practice Address - Phone:701-766-1612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AU46983207261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01056Medicaid
ND3503693OtherNCPDP
ND01056Medicaid