Healthcare Provider Details

I. General information

NPI: 1851168975
Provider Name (Legal Business Name): WAY OF LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 4TH ST N
FARGO ND
58102-4818
US

IV. Provider business mailing address

1709 13TH AVE S
FARGO ND
58103-3812
US

V. Phone/Fax

Practice location:
  • Phone: 701-581-5199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHEYENNE PUETZ
Title or Position: OWNER
Credential:
Phone: 701-581-5199