=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679709802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSJ ACQUISITION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2009
-----------------------------------------------------
Last Update Date | 04/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 4TH ST S
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-476-7200
-----------------------------------------------------
Fax | 701-280-5789
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 4TH ST S
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-476-7200
-----------------------------------------------------
Fax | 701-280-5789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SRVP CFO
-----------------------------------------------------
Name | STEVE FILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-768-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------