Healthcare Provider Details

I. General information

NPI: 1093937203
Provider Name (Legal Business Name): PEDIATRIC ARTS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3290 20TH ST S STE A
FARGO ND
58104-5923
US

IV. Provider business mailing address

3290 20TH ST S STE A
FARGO ND
58104-5923
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-4722
  • Fax: 701-893-9057
Mailing address:
  • Phone: 701-478-4722
  • Fax: 701-893-9057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateND

VIII. Authorized Official

Name: DR. ENDER RAGHIB
Title or Position: PRESIDENT
Credential: M.D.
Phone: 701-478-4722