Facts
- Status
- A
- Credential
- COTA
- Type
- Individual
- Enumeration date
- 2015-01-09
- Last updated
- 2026-07-29
Specialties
Licenses
- License ND
- 2087
Location
- Practice location
- 2500 FAIRWAY ST
- City
- DICKINSON ND
- Postal code
- 586012639
- Phone
- 701-456-4000
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.