NPIMap

Organization Active NPI

West Side Community Health Services, Inc.

Doing business as Creative Arts Clinic

  • Federally Qualified Health Center (FQHC)
  • Saint Paul, MN
National Provider Identifier
1205397395
Registry record updated Jul 8, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Doing business as
Creative Arts Clinic
Practice address
65 Kellogg Blvd E
Saint Paul, MN 55101-1106
Phone
(651) 602-7500
Fax
(651) 602-7580
NPI assigned
Mar 29, 2019
Last updated
Jul 8, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
WEST SIDE COMMUNITY HEALTH SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 8, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Reuben Moore
Title
Ceo
Phone
(651) 602-7537

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

65 Kellogg Blvd E
Saint Paul, MN 55101-1106

Mailing address

153 Cesar Chavez St
Saint Paul, MN 55107-2226
Phone (651) 602-7500

Other names 1

  • Creative Arts Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040209000647 MN Part B Supplier - Clinic/Group Practice 2062306434 Receives reassigned benefits from 116 practitioners
18 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Saint Paul, MN; Saint Paul Park, MN; Maplewood, MN; St. Paul, MN; Minneapolis, MN
O20250731003894 MN Part A Provider - Federally Qualified Health Center (FQHC) 2062306434 Practice locations: Saint Paul, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1205397395. Details of each certification follow.

Federally qualified health center certification: CCN 241006

Legal name
WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Doing business as
CREATIVE ARTS CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 31, 2025
Last certification
Jul 31, 2025
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
65 Kellogg Blvd E
School-Based Clinic Suite
Saint Paul, MN 55101-1106

Other NPIs with the same Medicare PAC ID 15

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 15

Other NPIs on the same Medicare enrollment 17

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 17

National Provider Directory

National Provider Directory
Tax ID family
West Side Community Health Service Inc22 organizations share this tax ID, including this one
Part of
West Side Community Health Service Inc

Other organizations with this tax ID 21

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

View all 21

Locations

65 Kellogg Blvd E
Saint Paul, MN 55101

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jessica Nickrand Individual Corporate Director Oct 1, 2023
Jana Nincovik Individual Corporate Director Sep 1, 2023
Daniel Rodriguez Individual Corporate Director Aug 26, 2020
Arnold L London Individual Corporate Director Jan 1, 2023
West Side Community Health Services, Inc. Organization, Saint Paul, MN Non-profit Operational/Managerial Control Nov 1, 2018 100%
Amelia Hardy Individual Corporate Director May 7, 2018
Cordell Hardy Individual Corporate Director May 7, 2018
Reuben Moore Individual Corporate Officer Oct 2, 2017
Operational/Managerial Control Oct 2, 2017
Callie K Chamberlain Individual Corporate Director Jan 1, 2021
Eric William Hanson Individual Corporate Officer Feb 28, 2022
W-2 Managing EmployeeRevenue Data & Credentialing MNGR Feb 28, 2022
Sarah Delfosse Individual Corporate Director Nov 1, 2023
Raul Noriega Individual Corporate Officer Sep 25, 2023
W-2 Managing EmployeeAd; Sep 25, 2023
Chestevia Gibson Individual Corporate Director Nov 1, 2023

Owners & managing parties with NPI records 16

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 16

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
West Side Community Health Services, Inc.Saint Paul, MN, CCN 241804 Federally qualified health center Operational/Managerial Control Dec 8, 1988

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1553817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751932800000",
    "number": "1205397395",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "153 CESAR CHAVEZ ST",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551072226",
            "telephone_number": "651-602-7500",
            "fax_number": "651-602-7513"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "65 KELLOGG BLVD E",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551011106",
            "telephone_number": "651-602-7500",
            "fax_number": "651-602-7580"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WEST SIDE COMMUNITY HEALTH SERVICES, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WEST SIDE COMMUNITY HEALTH SERVICES",
        "enumeration_date": "2019-03-29",
        "last_updated": "2025-07-08",
        "certification_date": "2025-07-08",
        "status": "A",
        "authorized_official_last_name": "MOORE",
        "authorized_official_first_name": "REUBEN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "651-602-7537"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Creative Arts Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Paul, MN

Sources for this page

Verify at the official NPI Registry.