Healthcare Provider Details

I. General information

NPI: 1891069191
Provider Name (Legal Business Name): ST. JAMES' OF NORTH DAKOTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 4TH AVE S
WISHEK ND
58495-7527
US

IV. Provider business mailing address

3120Z 25TH ST S # 344
FARGO ND
58103-5054
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-8008
  • Fax:
Mailing address:
  • Phone: 701-751-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7174
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number7174
License Number StateND

VIII. Authorized Official

Name: EMMET MICHAEL KENNEY JR.
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 701-751-8008