Provider Demographics
NPI:1316531817
Name:LIGHTHOUSE CHURCH OF FARGO
Entity type:Organization
Organization Name:LIGHTHOUSE CHURCH OF FARGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:SCHNASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-212-8626
Mailing Address - Street 1:21 9TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1830
Mailing Address - Country:US
Mailing Address - Phone:791-212-8626
Mailing Address - Fax:
Practice Address - Street 1:111 9TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1831
Practice Address - Country:US
Practice Address - Phone:701-212-8626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND251S00000XMedicaid
ND347C00000XMedicaid
ND251B00000XMedicaid