Individual
SUMMER TAKEN ALIVE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4909 SHELBURNE ST, BISMARCK, ND 58503-5605
(701) 223-2417
Mailing address
4909 SHELBURNE ST, BISMARCK, ND 58503-5605
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
172A00000X
Driver
—
—
174400000X
Specialist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1481505
—
ND
05
—
1481709
—
ND
Enumeration date
01/22/2021
Last updated
08/03/2021
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