Provider Demographics
NPI:1538661384
Name:COMMUNITY UPLIFT PROGRAM
Entity Type:Organization
Organization Name:COMMUNITY UPLIFT PROGRAM
Other - Org Name:HARBOR HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-639-3094
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-0909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:417 MAIN AVE STE 401
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1956
Practice Address - Country:US
Practice Address - Phone:701-799-7314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY UPLIFT PROGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-07
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty