Basic Information
| Provider Information | |||||||||
| NPI: | 1548430614 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE FAMILY SERVICE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014514891 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014514891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | HAUGEN | ||||||||
| AuthorizedOfficialFirstName: | CANDACE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF HUMAN RESOURCES | ||||||||
| AuthorizedOfficialTelephone: | 7014514900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 261QM0801X | 1142 | ND | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 54631 | 05 | ND | MEDICAID | 454484600 | 05 | MN | MEDICAID | 57527 | 05 | ND | MEDICAID |