Healthcare Provider Details

I. General information

NPI: 1750102026
Provider Name (Legal Business Name): AWESOME INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 53RD AVE S UNIT E
FARGO ND
58104-5762
US

IV. Provider business mailing address

6020 53RD AVE S UNIT E
FARGO ND
58104-5762
US

V. Phone/Fax

Practice location:
  • Phone: 701-356-5090
  • Fax: 701-356-5091
Mailing address:
  • Phone: 701-356-5090
  • Fax: 701-356-5091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: GINA SCHUMACHER
Title or Position: PRESIDENT
Credential:
Phone: 701-318-2133