Healthcare Provider Details

I. General information

NPI: 1598952194
Provider Name (Legal Business Name): FARGO VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 27TH ST W STE 210
WILLISTON ND
58801-5453
US

IV. Provider business mailing address

PO BOX 94452
CLEVELAND OH
44101-4452
US

V. Phone/Fax

Practice location:
  • Phone: 913-578-4409
  • Fax: 913-578-4536
Mailing address:
  • Phone: 913-578-4409
  • Fax: 913-578-4536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN POTTER
Title or Position: NPI TEAM
Credential:
Phone: 202-382-2579