Healthcare Provider Details

I. General information

NPI: 1316531817
Provider Name (Legal Business Name): LIGHTHOUSE CHURCH OF FARGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 9TH ST S
FARGO ND
58103-1831
US

IV. Provider business mailing address

21 9TH ST S
FARGO ND
58103-1830
US

V. Phone/Fax

Practice location:
  • Phone: 701-212-8626
  • Fax:
Mailing address:
  • Phone: 791-212-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MELINDA FAYE SCHNASE
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 701-212-8626