Provider Demographics
NPI:1699809939
Name:WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Other - Org Name:AGAPE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:BREHM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-602-7536
Mailing Address - Street 1:153 CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2226
Mailing Address - Country:US
Mailing Address - Phone:651-222-1816
Mailing Address - Fax:651-222-1305
Practice Address - Street 1:1919 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3453
Practice Address - Country:US
Practice Address - Phone:651-632-2189
Practice Address - Fax:651-632-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103124OtherUCARE
MN724657100Medicaid
MN724657100Medicaid
MN103124OtherUCARE