Provider Demographics
NPI:1821303397
Name:CHI HEALTH CONNECT AT HOME - FARGO
Entity Type:Organization
Organization Name:CHI HEALTH CONNECT AT HOME - FARGO
Other - Org Name:CHI HEALTH AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OPERATIONS/AUTH OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEYERL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-238-3206
Mailing Address - Street 1:4265 45TH ST S STE 2
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4309
Mailing Address - Country:US
Mailing Address - Phone:701-237-8116
Mailing Address - Fax:701-237-8188
Practice Address - Street 1:1110 HIGHWAY 75 NORTH
Practice Address - Street 2:SUITE A
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1117
Practice Address - Country:US
Practice Address - Phone:218-643-2275
Practice Address - Fax:218-643-2274
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONSPIRIT HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-09
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN346249251G00000X
MN251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN376289Medicaid
MN241510Medicare Oscar/Certification