Provider Demographics
NPI:1881001618
Name:GRAND FORKS HEAD START
Entity type:Organization
Organization Name:GRAND FORKS HEAD START
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:701-746-2433
Mailing Address - Street 1:3600 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-2723
Mailing Address - Country:US
Mailing Address - Phone:701-746-2433
Mailing Address - Fax:701-746-2450
Practice Address - Street 1:3600 6TH AVE N
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-2723
Practice Address - Country:US
Practice Address - Phone:701-746-2433
Practice Address - Fax:701-746-2450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR22445252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND59921Medicaid