Provider Demographics
NPI:1801190772
Name:ST. WILL'S, LLC
Entity Type:Organization
Organization Name:ST. WILL'S, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMET
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:701-577-5700
Mailing Address - Street 1:3137 32ND AVE S
Mailing Address - Street 2:SUITE 223
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6159
Mailing Address - Country:US
Mailing Address - Phone:701-577-5700
Mailing Address - Fax:
Practice Address - Street 1:3137 32ND AVE S
Practice Address - Street 2:SUITE 223
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6159
Practice Address - Country:US
Practice Address - Phone:701-577-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7174261QA0600X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care