Healthcare Provider Details

I. General information

NPI: 1154200673
Provider Name (Legal Business Name): SPHERALIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 33RD ST S APT 202
FARGO ND
58103-7830
US

IV. Provider business mailing address

3120 33RD ST S APT 202
FARGO ND
58103-7830
US

V. Phone/Fax

Practice location:
  • Phone: 818-300-6430
  • Fax:
Mailing address:
  • Phone: 818-300-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: RUTH IVANOV
Title or Position: CEO
Credential: QDDP
Phone: 818-300-6430