Provider Demographics
NPI:1861183105
Name:MORNINGSTAR CLINIC, LLC
Entity type:Organization
Organization Name:MORNINGSTAR CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIES
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:608-444-2765
Mailing Address - Street 1:PO BOX 10083
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58106-0083
Mailing Address - Country:US
Mailing Address - Phone:608-444-2765
Mailing Address - Fax:
Practice Address - Street 1:3015 30TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6119
Practice Address - Country:US
Practice Address - Phone:608-444-2765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty