Provider Demographics
NPI:1194358739
Name:FARGO VAMC
Entity Type:Organization
Organization Name:FARGO VAMC
Other - Org Name:FARGO VA CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:NPI TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 94452
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4452
Mailing Address - Country:US
Mailing Address - Phone:913-578-4409
Mailing Address - Fax:913-578-4536
Practice Address - Street 1:721 1ST AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4903
Practice Address - Country:US
Practice Address - Phone:913-578-4409
Practice Address - Fax:913-578-4536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-21
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA