Balm of Gilead Healthcare Clinic LLC

Key facts

NPI: 1154022895
Entity type: Organization (NPI type 2)
Primary specialty: Psychiatric/Mental Health Nurse Practitioner 363LP0808X
Legal business name: BALM OF GILEAD HEALTHCARE CLINIC LLC
Practice address: 210 Gateway Dr NE Ste 1
East Grand Forks, MN 56721-1621
Phone: (218) 207-2020
Fax: (800) 582-1083
NPI assigned: Mar 10, 2023
Organization subpart: No

Authorized official

Name: Merit Fongwi Laduna Fondong NPI 1306221460
Title: NP
Phone: (218) 779-9437

Authorized official NPPES reports the authorized official by name only; the link goes to the one practitioner connected to this organization with that name.

Corporate family (same tax ID) 1

Organizations that report the same tax identification number in the National Provider Directory.

Balm of Gilead Healthcare LLC Psychiatric/Mental Health Nurse Practitioner · East Grand Forks, MN · NPI 1730889882

NPD tax ID

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Merit FL Fondong, NP Psychiatric/Mental Health Nurse Practitioner · East Grand Forks, MN · NPI 1306221460

Medicare reassignment Care Compare group NPD Authorized official MN · PSYCHIATRIC/MENTAL HEALTH
Kimberly Nicole Williams, APRN, FNP-C Family Nurse Practitioner · East Grand Forks, MN · NPI 1639693864

Medicare reassignment Care Compare group NPD MN
Timothy Tita Etonde, DNP Psychiatric/Mental Health Nurse Practitioner · Fargo, ND · NPI 1811787666

Medicare reassignment Care Compare group NPD MN · SINGLE SPECIALTY

Medicare participation

Medicare fee-for-service enrollment: Enrolled in MN

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
O20230424002616	MN	Part B Supplier - Clinic/Group Practice	0648635714	Receives reassigned benefits from 3 practitioners Practice locations: East Grand Forks, MN

National Provider Directory

Tax ID family: Balm of Gilead Healthcare Clinic (2 organizations share this tax ID)

Locations

1618 Central Ave NE
East Grand Forks, MN 56721
Phone (218) 779-9437

210 Gateway Dr NE
Ste 1
East Grand Forks, MN 56721
Phone (218) 207-2020

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Psychiatric/Mental Health Nurse Practitioner Group: 193200000X MULTI-SPECIALTY GROUP	363LP0808X			Yes
Primary Care Nurse Practitioner Group: 193200000X MULTI-SPECIALTY GROUP	363LP2300X

Addresses

Primary practice location

210 Gateway Dr NE Ste 1
East Grand Forks, MN 56721-1621

Mailing address

210 Gateway Dr NE Ste 1
East Grand Forks, MN 56721-1621
Phone (218) 207-2020

Other providers in East Grand Forks, MN

All providers in East Grand Forks, MN · Psychiatric/Mental Health Nurse Practitioner in Minnesota

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 10, 2025. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.