Provider Demographics
NPI:1083928048
Name:CHI HEALTH CONNECT AT HOME-FARGO
Entity Type:Organization
Organization Name:CHI HEALTH CONNECT AT HOME-FARGO
Other - Org Name:CHI HEALTH AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OPERATIONS/AUTH OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEYERL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-238-3206
Mailing Address - Street 1:4265 45TH ST S STE 200
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4309
Mailing Address - Country:US
Mailing Address - Phone:701-237-8116
Mailing Address - Fax:701-237-8188
Practice Address - Street 1:1301 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3821
Practice Address - Country:US
Practice Address - Phone:701-774-7430
Practice Address - Fax:701-774-7465
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONSPIRIT HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-02
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4033A251E00000X
ND251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND4033Medicaid
ND4033Medicaid