Provider Demographics
NPI:1407443245
Name:VILLA NAZARETH
Entity Type:Organization
Organization Name:VILLA NAZARETH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-235-8217
Mailing Address - Street 1:801 PAGE DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2315
Mailing Address - Country:US
Mailing Address - Phone:701-235-8217
Mailing Address - Fax:701-235-7538
Practice Address - Street 1:801 PAGE DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2315
Practice Address - Country:US
Practice Address - Phone:701-235-8217
Practice Address - Fax:701-235-7538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1456353Medicaid