Basic Information
| Provider Information | |||||||||
| NPI: | 1952679318 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE FAMILY SERVICE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | PO BOX 9859 | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014514891 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 12TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581038753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012933384 | ||||||||
| FaxNumber: | 7012933384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2011 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | HAUGEN | ||||||||
| AuthorizedOfficialFirstName: | CANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF HUMAN RESOURCES | ||||||||
| AuthorizedOfficialTelephone: | 7014514900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIRST STEP RECOVERY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1142 | ND | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QM0801X | 1142 | ND | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 3Z71FI | 01 | MN | UBH | OTHER | 8441481 | 01 | MN | BCBSMN | OTHER |