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General NPI Number Information
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NPI Number | 1538661384
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Entity Type | Organization
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Legal Business Name | COMMUNITY UPLIFT PROGRAM
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Dates
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Enumeration Date | 03/07/2018
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Last Update Date | 10/12/2018
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Provider Practice Location Address
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Address Line | 417 MAIN AVE STE 401
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City | FARGO
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State | ND
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Zip | 58103-1956
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Country | US
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Telephone | 701-799-7314
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 909
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City | FARGO
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State | ND
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Zip | 58107-0909
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | CODY SEVERSON
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Credential |
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Telephone | 701-639-3094
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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