Provider Demographics
NPI:1548430614
Name:VILLAGE FAMILY SERVICE CENTER
Entity Type:Organization
Organization Name:VILLAGE FAMILY SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF HUMAN RESOURCES
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-451-4900
Mailing Address - Street 1:1201 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:701-451-4891
Practice Address - Street 1:1201 25TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2311
Practice Address - Country:US
Practice Address - Phone:701-451-4900
Practice Address - Fax:701-451-4891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
ND1142261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54631Medicaid
MN454484600Medicaid
ND57527Medicaid
MN454484600Medicaid
ND1000283Medicare PIN