MEDICARE: ST JAMES OF ND, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center	7174	ND
2	261QM0850X	Adult Mental Health Clinic/Center	7174	ND

General Provider Information

NPI Number	:	1538463401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST JAMES OF ND, LLC

Provider Business Mailing Address
First Line	:	3120 25TH ST S STE Z
Second Line	:	#344
City	:	FARGO
State	:	ND
Zip	:	58103-6164
Country	:	US
Telephone Number	:	701-365-4467
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 NORTH 14TH STREET
Second Line	:	SUITE 2A
City	:	BISMARCK
State	:	ND
Zip	:	58503
Country	:	US
Telephone Number	:	701-361-6640
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EMMET MICHAEL KENNEY JR.
Credential	:	M.D.
Telephone Number	:	701-361-6640

Provider Enumeration Date	:	01/06/2011
Last Update Date	:	04/03/2013

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