Healthcare Provider Details

I. General information

NPI: 1538463401
Provider Name (Legal Business Name): ST JAMES OF ND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NORTH 14TH STREET SUITE 2A
BISMARCK ND
58503
US

IV. Provider business mailing address

3120 25TH ST S STE Z #344
FARGO ND
58103-6164
US

V. Phone/Fax

Practice location:
  • Phone: 701-361-6640
  • Fax:
Mailing address:
  • Phone: 701-365-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7174
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number7174
License Number StateND

VIII. Authorized Official

Name: DR. EMMET MICHAEL KENNEY JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 701-361-6640