Provider Demographics
NPI:1831232115
Name:VINGER, CLYDE
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:VINGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 KNOLL ST
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3234
Mailing Address - Country:US
Mailing Address - Phone:701-572-8083
Mailing Address - Fax:
Practice Address - Street 1:1415 W DAKOTA PKWY
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3885
Practice Address - Country:US
Practice Address - Phone:701-572-6757
Practice Address - Fax:701-774-3532
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND669225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND50824Medicaid