1578567996 NPI number — SISTERS OF MARY OF THE PRESENTATION LONG-TERM CARE

Table of content: (NPI 1578567996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578567996 NPI number — SISTERS OF MARY OF THE PRESENTATION LONG-TERM CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SISTERS OF MARY OF THE PRESENTATION LONG-TERM CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ROSEWOOD ON BROADWAY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578567996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1351 BROADWAY N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58102-2638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-277-7999
Provider Business Mailing Address Fax Number:
701-277-7989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1351 BROADWAY N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58102-2638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-277-7999
Provider Business Practice Location Address Fax Number:
701-277-7989
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TANG
Authorized Official First Name:
MELDINE
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
701-277-7999

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1022A , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12518 . This is a "BLUE CROSS ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 30420 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9F64R0 . This is a "BLUE CROSS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 687667600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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