Provider Demographics
NPI:1023286614
Name:CLINIC FHSC PC
Entity type:Organization
Organization Name:CLINIC FHSC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-492-0696
Mailing Address - Street 1:1207 PRAIRIE PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1207 PRAIRIE PKWY
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3145
Practice Address - Country:US
Practice Address - Phone:701-492-0696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND22991OtherBLUE CROSS BLUE SHIELD ND
ND1451977Medicaid
MN01B40THOtherBLUE CROSS BLUE SHIELD MN
NDDE5709OtherMEDICARE RAILROAD
ND13377Medicaid
ND22991OtherBLUE CROSS BLUE SHIELD ND