Provider Demographics
NPI:1073601258
Name:PRAIRIE ST. JOHN'S CLINIC
Entity Type:Organization
Organization Name:PRAIRIE ST. JOHN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MAGNISON
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:701-476-7221
Mailing Address - Street 1:510 4TH ST S
Mailing Address - Street 2:PO BOX 2027
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1914
Mailing Address - Country:US
Mailing Address - Phone:701-476-7221
Mailing Address - Fax:701-476-7261
Practice Address - Street 1:7616 CURRELL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2290
Practice Address - Country:US
Practice Address - Phone:651-259-9700
Practice Address - Fax:651-259-9740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5063A261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN238T5PROtherMINNESOTA BLUE CROSS