Provider Demographics
NPI:1417784323
Name:FAITH RESTORED ENTERPRISE LLC
Entity type:Organization
Organization Name:FAITH RESTORED ENTERPRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:JAYLEE
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, MPH
Authorized Official - Phone:267-971-8143
Mailing Address - Street 1:5509 36TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5216
Mailing Address - Country:US
Mailing Address - Phone:267-971-8143
Mailing Address - Fax:
Practice Address - Street 1:5509 36TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5216
Practice Address - Country:US
Practice Address - Phone:267-971-8143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAITH RESTORED ENTERPRISE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)