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General NPI Number Information
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NPI Number | 1215831177
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Entity Type | Organization
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Legal Business Name | TELLEGACY LLC
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Dates
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Enumeration Date | 10/05/2026
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Last Update Date | 10/05/2026
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Provider Practice Location Address
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Address Line | 3523 45TH ST S # 164
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City | FARGO
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State | ND
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Zip | 58104-8962
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Country | US
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Telephone | 419-270-7511
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Fax |
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Provider Business Mailing Address
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Address Line | 3523 45TH ST S
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City | FARGO
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State | ND
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Zip | 58104-8962
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Country | US
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Telephone | 419-270-7511
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. JEREMY CHRISTOPHER HOLLOWAY
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Credential | PHD, MBA
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Telephone | 419-270-7511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State | NULL
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Taxonomy #2
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Taxonomy Code | 261QR1100X
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Taxonomy Name | Research Clinic/Center
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License Number |
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License Number State | NULL
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Taxonomy #3
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State | NULL
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | NULL
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