Healthcare Provider Details

I. General information

NPI: 1679709802
Provider Name (Legal Business Name): PSJ ACQUISITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 4TH ST S
FARGO ND
58103
US

IV. Provider business mailing address

510 4TH ST S
FARGO ND
58103
US

V. Phone/Fax

Practice location:
  • Phone: 701-476-7200
  • Fax: 701-280-5789
Mailing address:
  • Phone: 701-476-7200
  • Fax: 701-280-5789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: STEVE FILTON
Title or Position: SRVP CFO
Credential:
Phone: 610-768-3300