| Details | Last Recertification Date | Update | Recertification | 2/1/2024 8:19:59 AM | 2/14/2025 11:20:25 AM | 2/14/2025 11:20 AM |
| Details | Last Recertification Date | Update | Recertification | 2/2/2023 2:52:49 PM | 2/1/2024 8:19:59 AM | 2/1/2024 8:19 AM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2022 12:28:25 PM | 2/2/2023 2:52:49 PM | 2/2/2023 2:52 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 7/29/2022 2:51 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 955353300 | 7/29/2022 2:51 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | MN | 7/29/2022 2:51 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1114069911 | 7/29/2022 2:51 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MN | 7/29/2022 2:51 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1871755975 | 7/29/2022 2:51 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MN | 7/29/2022 2:51 PM |
| Addresses | Shipping Address | Insert | Change Request | | West Side Community Health Services, Inc.
153 Cesar Chavez Street
St. Paul, MN 55107 | 7/26/2022 1:34 PM |
| Addresses | Shipping Address | Insert | Change Request | | West Side Community Health Services, Inc.
895 7th St. E.
St. Paul, MN 55106 | 7/26/2022 1:34 PM |
| Contacts | Primary Contact | Update | Recertification | Darsow, Blake Robert
Chief Financial Officer
West Side Community Health Services, Inc.
6123873721 | Nelson, Kenneth Scott
Director of Pharmacy
West Side Community Health Services
7155660729 | 2/8/2022 12:28 PM |
| Details | Last Recertification Date | Update | Recertification | 2/21/2021 11:42:54 PM | 2/8/2022 12:28:25 PM | 2/8/2022 12:28 PM |
| Contacts | Authorizing Official | Update | Group Change Request | Moore, Reuben
President & Executive Officer
Westside Community Health Services, Inc. dba Minnesota Community Care
6516027536 | Moore, Reuben
President and Executive Officer
West Side Community Health Services
6516027536 | 1/14/2022 6:57 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Moore, Reuben
CEO
Westside Community Health Services
6516027536 | Moore, Reuben
President & Executive Officer
Westside Community Health Services, Inc. dba Minnesota Community Care
6516027536 | 9/28/2021 6:37 AM |
| Contacts | Signed By | Update | Profile Change Request | Moore, Reuben
CEO
Westside Community Health Services
6516027536 | Moore, Reuben
President & Executive Officer
Westside Community Health Services, Inc. dba Minnesota Community Care
6516027536 | 9/28/2021 6:37 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/21/2021 11:42 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 112383100 | 2/21/2021 11:42 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MN | 2/21/2021 11:42 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | MN | 2/21/2021 11:42 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2020 3:52:56 PM | 2/21/2021 11:42:54 PM | 2/21/2021 11:42 PM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2019 7:13:03 AM | 1/31/2020 3:52:56 PM | 1/31/2020 3:52 PM |
| Contacts | Primary Contact | Update | Change Request | Killelea, Dirk
Pharmacy Services Manager
Westside Community Health Services
6513892415 | Darsow, Blake Robert
Chief Financial Officer
West Side Community Health Services, Inc.
6123873721 | 11/25/2019 12:44 PM |
| Details | Last Recertification Date | Update | Recertification | 2/2/2017 12:00:00 AM | 2/1/2019 7:13:03 AM | 2/1/2019 7:13 AM |
| Terminations | Termination Reason | Update | | Failure to recertify | | 7/21/2018 12:21 PM |
| Details | State | Update | | Approved | Active | 7/1/2018 12:00 AM |
| Addresses | Main Address | Insert | Reinstatement | |
1540 6th St E
Saint Paul, MN 55106-4806 | 4/20/2018 3:03 PM |
| Addresses | Billing Address | Insert | Reinstatement | | WEST SIDE COMMUNITY HEALTH SERVICES, INC.
153 CESAR CHAVEZ STREET
ST PAUL, MN 55107 | 4/20/2018 3:03 PM |
| Contacts | Primary Contact | Update | Reinstatement | FOURNIER, JAESON
CEO
6516027536 | Killelea, Dirk
Pharmacy Services Manager
Westside Community Health Services
6513892415 | 4/20/2018 3:03 PM |
| Contacts | Authorizing Official | Update | Reinstatement | FOURNIER, JAESON
CEO
6516027536 | Moore, Reuben
CEO
Westside Community Health Services
6516027536 | 4/20/2018 3:03 PM |
| Contacts | Signed By | Insert | Reinstatement | | Moore, Reuben
CEO
Westside Community Health Services
6516027536 | 4/20/2018 3:03 PM |
| Dates | Participating Approval Date | Update | Reinstatement | | 4/20/2018 3:03:39 PM | 4/20/2018 3:03 PM |
| Details | State | Update | Reinstatement | Pending | Approved | 4/20/2018 3:03 PM |
| Dates | Signed By Date | Update | Reinstatement | 12/23/2009 12:00:00 AM | 4/3/2018 4:04:55 PM | 4/20/2018 3:03 PM |
| Dates | Start Date | Update | Reinstatement | | 7/1/2018 12:00:00 AM | 4/20/2018 3:03 PM |
| Terminations | Termination Reason | Update | Reinstatement | | Failure to recertify | 4/20/2018 3:03 PM |
| Details | Comments Public | Insert | Reinstatement | | Participation started on 4/1/2010; terminated on 4/1/2018; Reinstated on 7/1/2018. | 4/20/2018 8:34 AM |
| Details | Comments Public | Insert | Reinstatement | | Participation started on 3/10/2010; terminated on 4/1/2018; Reinstated on 7/1/2018. | 4/6/2018 11:34 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 4/1/2018 12:00:00 AM | | 4/1/2018 1:41 PM |
| Dates | Participating Approval Date | Update | Reinstatement | 3/10/2010 12:00:00 AM | | 4/1/2018 1:41 PM |
| Details | State | Update | Reinstatement | Terminated | Pending | 4/1/2018 1:41 PM |
| Dates | Registration Date | Update | Reinstatement | 2/25/2010 12:00:00 AM | 4/1/2018 1:41:41 PM | 4/1/2018 1:41 PM |
| Dates | Start Date | Update | Reinstatement | 4/1/2010 12:00:00 AM | | 4/1/2018 1:41 PM |
| Terminations | Termination Date | Update | Reinstatement | 4/1/2018 12:00:00 AM | | 4/1/2018 1:41 PM |
| Terminations | Termination Effective Date | Update | Reinstatement | 4/1/2018 12:00:00 AM | | 4/1/2018 1:41 PM |
| Terminations | Termination Reason | Update | Reinstatement | Failure to recertify | | 4/1/2018 1:41 PM |
| Details | State | Update | | To Be Terminated | Terminated | 4/1/2018 12:00 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 4/1/2018 12:00:00 AM | 3/8/2018 2:38 PM |
| Details | State | Update | Recertification | Active | To Be Terminated | 3/8/2018 2:38 PM |
| Terminations | Termination Date | Update | Recertification | | 4/1/2018 12:00:00 AM | 3/8/2018 2:38 PM |
| Terminations | Termination Effective Date | Update | Recertification | | 4/1/2018 12:00:00 AM | 3/8/2018 2:38 PM |
| Terminations | Termination Reason | Update | Recertification | | Failure to recertify | 3/8/2018 2:38 PM |
| Addresses | Main Address | Insert | | |
1540 6th St E
Saint Paul, MN 55106-4806 | 2/2/2017 10:43 AM |
| Contacts | Authorizing Official | Insert | | | FOURNIER, JAESON
CEO
6516027536 | 2/2/2017 10:43 AM |
| Contacts | Primary Contact | Insert | | | FOURNIER, JAESON
CEO
6516027536 | 2/2/2017 10:43 AM |
| Details | Last Recertification Date | Update | | 2/24/2016 12:00:00 AM | 2/2/2017 12:00:00 AM | 2/2/2017 10:43 AM |
| Details | Last Recertification Date | Update | | 2/11/2015 12:00:00 AM | 2/24/2016 12:00:00 AM | 2/24/2016 12:27 PM |
| Details | Last Recertification Date | Update | | 2/17/2014 12:00:00 AM | 2/11/2015 12:00:00 AM | 2/11/2015 12:13 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 2/17/2014 12:00:00 AM | 2/17/2014 2:39 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1881887032 | 3/20/2013 12:46 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 3/20/2013 12:46 PM |
| Addresses | Billing Address | Insert | | | WEST SIDE COMMUNITY HEALTH SERVICES
153 CESAR CHAVEZ STREET
ST PAUL, MN 55107 | 1/28/2013 12:40 PM |
| Addresses | Billing Address | Update | | WEST SIDE COMMUNITY HEALTH SERVICES
153 CESAR CHAVEZ STREET
ST PAUL, MN 55107 | WEST SIDE COMMUNITY HEALTH SERVICES, INC.
153 CESAR CHAVEZ STREET
ST PAUL, MN 55107 | 1/28/2013 12:40 PM |
| Details | Entity Name | Update | | WEST SIDE COMMUNITY HEALTH SERVICES | WEST SIDE COMMUNITY HEALTH SERVICES, INC. | 1/28/2013 12:40 PM |
| Details | Entity Subname | Update | | HARDING HIGH SCHOOL | HARDING HIGH SCHOOL CLINIC | 1/28/2013 12:40 PM |
| Details | Last Recertification Date | Insert | | | | 3/26/2010 12:21 PM |
| Details | Grant Number | Insert | | | H80CS00790 | 3/26/2010 12:21 PM |
| Details | 340B ID | Insert | | | CH05302S | 3/26/2010 12:21 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 3/26/2010 12:21 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 3/26/2010 12:21 PM |
| Details | Medicare Provider Number | Insert | | | | 3/26/2010 12:21 PM |
| Details | Entity Name | Insert | | | WEST SIDE COMMUNITY HEALTH SERVICES | 3/26/2010 12:21 PM |
| Details | Program Code | Insert | | | CH | 3/26/2010 12:21 PM |
| Details | Entity Subname | Insert | | | HARDING HIGH SCHOOL | 3/26/2010 12:21 PM |
| Dates | Participating Approval Date | Insert | | | 3/10/2010 12:00:00 AM | 3/26/2010 12:21 PM |
| Details | State | Insert | | | Active | 3/26/2010 12:21 PM |
| Dates | Registration Date | Insert | | | 2/25/2010 12:00:00 AM | 3/26/2010 12:21 PM |
| Dates | Signed By Date | Insert | | | 12/23/2009 12:00:00 AM | 3/26/2010 12:21 PM |
| Dates | Start Date | Insert | | | 4/1/2010 12:00:00 AM | 3/26/2010 12:21 PM |
| Terminations | Termination Comments | Insert | | | | 3/26/2010 12:21 PM |
| Terminations | Termination Date | Insert | | | | 3/26/2010 12:21 PM |
| Terminations | Termination Effective Date | Insert | | | | 3/26/2010 12:21 PM |
| Terminations | Termination Reason | Insert | | | | 3/26/2010 12:21 PM |