Healthcare Provider Details

I. General information

NPI: 1154022895
Provider Name (Legal Business Name): BALM OF GILEAD HEALTHCARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 GATEWAY DR NE STE 1
EAST GRAND FORKS MN
56721-1621
US

IV. Provider business mailing address

210 GATEWAY DR NE STE 1
EAST GRAND FORKS MN
56721-1621
US

V. Phone/Fax

Practice location:
  • Phone: 218-207-2020
  • Fax: 800-582-1083
Mailing address:
  • Phone: 218-207-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MERIT FONGWI LADUNA FONDONG
Title or Position: NP
Credential:
Phone: 218-779-9437