Provider Demographics
NPI:1265963250
Name:THE VILLAGE FAMILY SERVICE CENTER
Entity type:Organization
Organization Name:THE VILLAGE FAMILY SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-451-4900
Mailing Address - Street 1:1201 25TH ST S
Mailing Address - Street 2:PO BOX 9859
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 8TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-3605
Practice Address - Country:US
Practice Address - Phone:701-451-4855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN454484600Medicaid
MN596357500Medicaid
MN454484600Medicaid