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General NPI Number Information
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NPI Number | 1154022895
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Entity Type | Organization
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Legal Business Name | BALM OF GILEAD HEALTHCARE CLINIC LLC
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Dates
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Enumeration Date | 03/10/2023
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Last Update Date | 02/10/2025
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Provider Practice Location Address
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Address Line | 210 GATEWAY DR NE STE 1
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City | EAST GRAND FORKS
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State | MN
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Zip | 56721-1621
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Country | US
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Telephone | 218-207-2020
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Fax | 800-582-1083
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Provider Business Mailing Address
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Address Line | 210 GATEWAY DR NE STE 1
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City | EAST GRAND FORKS
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State | MN
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Zip | 56721-1621
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Country | US
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Telephone | 218-207-2020
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Fax |
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Authorized Official
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Title or Position | NP
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Name | MERIT FONGWI LADUNA FONDONG
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Credential |
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Telephone | 218-779-9437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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