Organization
PRAIRIE ST. JOHN'S CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JERRY W MAGNISON CFO (CHIEF FINANCIAL OFFICER)
(701) 476-7221
Entity
Organization
Contact information
Practice address
7616 CURRELL BLVD, SUITE 100, WOODBURY, MN 55125-2290
(651) 259-9700
(651) 259-9740
Mailing address
510 4TH ST S, PO BOX 2027, FARGO, ND 58103-1914
(701) 476-7221
(701) 476-7261
Taxonomy
Speciality
Code
Description
License number
State
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
5063A
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
238T5PR
MINNESOTA BLUE CROSS
MN
Enumeration date
10/11/2006
Last updated
08/22/2020
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