Healthcare Provider Details

I. General information

NPI: 1922055243
Provider Name (Legal Business Name): SOUTHEAST HUMAN SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 9TH AVE S
FARGO ND
58103-2350
US

IV. Provider business mailing address

2624 9TH AVE S
FARGO ND
58103-2350
US

V. Phone/Fax

Practice location:
  • Phone: 701-298-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier035434
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: CANDACE CAE FUGLESTEN
Title or Position: DIRECTOR
Credential:
Phone: 701-298-4500