Healthcare Provider Details

I. General information

NPI: 1659547669
Provider Name (Legal Business Name): PETERSON TCS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 4TH AVE S
FARGO ND
58103-8210
US

IV. Provider business mailing address

1205 4TH AVE S
FARGO ND
58103-8210
US

V. Phone/Fax

Practice location:
  • Phone: 701-237-0004
  • Fax: 701-237-0029
Mailing address:
  • Phone: 701-237-0004
  • Fax: 701-237-0029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number336384
License Number StateMN

VII. Legacy identifiers

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

# 1
Identifier994613600
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 2
Identifier1456810
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: JOEL K PETERSON
Title or Position: OWNER
Credential:
Phone: 701-237-0004