Provider Demographics
NPI:1174284699
Name:WEST SIDE COMMUNITY HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:WEST SIDE COMMUNITY HEALTH SERVICES, INC
Other - Org Name:FARMINGTON CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-602-7537
Mailing Address - Street 1:380 E LAFAYETTE FRONTAGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1216
Mailing Address - Country:US
Mailing Address - Phone:651-602-7552
Mailing Address - Fax:651-222-1305
Practice Address - Street 1:19685 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-7238
Practice Address - Country:US
Practice Address - Phone:651-602-7500
Practice Address - Fax:651-222-1305
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST SIDE COMMUNITY HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-06
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)