Healthcare Provider Details

I. General information

NPI: 1215831177
Provider Name (Legal Business Name): TELLEGACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3523 45TH ST S # 164
FARGO ND
58104-8962
US

IV. Provider business mailing address

3523 45TH ST S
FARGO ND
58104-8962
US

V. Phone/Fax

Practice location:
  • Phone: 419-270-7511
  • Fax:
Mailing address:
  • Phone: 419-270-7511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JEREMY CHRISTOPHER HOLLOWAY
Title or Position: DIRECTOR
Credential: PHD, MBA
Phone: 419-270-7511